“The Four Ds” of psychological abnormality

• Deviance – Different, extreme, unusual
• ́Distress – Unpleasant & upsetting
• Dysfunction – Causes interference with life
• ́Danger – Poses risk of harm

Why are the causes important?

1. Prevention
2. Treatment!

The DSM-5 TR

• Lists hundreds of mental disorders;
• Focused on pathology;
• Describes criteria for diagnoses, key clinical
  features, and related features which are
  often but not always present;
• NOT about etiology or treatment;
• People can be diagnosed with multiple
  disorders
• Used to be multiaxial.

What are the pros of diagnosis?

• ́Helpful in determining disease course
• Helpful in planning treatment
• Helpful in allaying the fears of the patient
• ́Communication with others, including insurance

What are the cons of diagnosis?

• Real life doesnʼt always match neat categories (e.g., bipolar)
• Clinicians can become lazy or overly simplistic, missing the whole person
• Labels follow people
• Ethical issues regarding insurance billing
• Differential issues
• Is it as accurate and helpful as we think?

First, collect information

• Interview;
• ”Collateral” interviews;
• Observations;
• Possibly formal
  assessments.

Next, funnel information:

1. Broad diagnostic categories (e.g., Mood Disorders)
2. "Differential diagnosis"
3. Final (current) diagnosis!

PRINCIPLES OF DIAGNOSIS

• Generally focus on the present
• Be thorough
• Be concise
• Be holistic
• Don’t stretch the truth
• Use exact, clinical terms
  • Differentiate between certainty, probability, and need to investigate further
    • Provisional (DSM - p. 25)
    • Rule Out (R/O) – old but helpful!

ANXIETY DISORDERS

• Separation Anxiety Disorder
• Selective Mutism
• Specific Phobia
• Social Anxiety Disorder (Social Phobia)
• Panic Disorder
• Agoraphobia
• Generalized Anxiety Disorder

SEPARATION ANXIETY DISORDER

Inappropriate and excessive anxiety
concerning separation from home or
attachment figure, with 3+ of:
• Excessive distress around separation
• Worry about losing attachment figures
• Worry about an event that would
separate them from attachment figures
• Refusal to go to school or elsewhere
• Refusal to be alone or go to sleep
• Nightmares about separation
• Physical complaints around separation
• 4+ weeks (children) or 6 months (adults)

SELECTIVE MUTISM

Not speaking in social situations
despite:
• Speaking in other places
• The expectation to speak, and
• The ability to speak
• Causes social or academic
impairment
• 1+ mos
• Not because of lack of knowledge
or a cultural issue

PHOBIAS

• Persistent and unreasonable fears of particular objects, activities, or situations
• Particular fear avoided (physically & mentally)
• 3 types: Specific/Simple, Social, Agoraphobia
• How do phobias differ from “normal” experiences?

SPECIFIC PHOBIA

Persistent fears of specific objects or
situations--either avoided or endured with
marked distress
• Exposure leads to fear & possibly Panic
Attack
• Fear or anxiety is out of proportion to
actual situation or vent
• 6+ mos.
• Specifiers (p. 224-5)

OBSESSIVE-COMPULSIVE DISORDERS

• Obsessive-Compulsive Disorder
• Body Dysmorphic Disorder
• Hoarding Disorder
• Trichotillomania
• Excoriation (Skin-Picking) Disorder
• And the usuals... (Substance/Medication-Induced, ___ Due to A Medical Condition, Other Specified, Unspecified)

OBSESSIVE-COMPULSIVE DISORDER

• 1) Obsessions: Cause marked anxiety/distress Recurrent and persistent thoughts
  Not simply worry over real-life problems
  The person recognizes thoughts are products of their own mind and attempts to ignore or suppress them
  2) (or) Compulsions: Serve to neutralize anxiety
  Repetitive behaviors (e.g., checking, hand-washing
  Rigid rules regarding rituals
  Behaviors or mental acts aimed at reducing distress or preventing a dreaded event (even though highly unrealistic)
  3. Takes a lot of time and interferes with life

BODY DYSMORPHIC DISORDER

Preoccupation with an imagined or exaggerated defect in appearance
Repetitive behaviors or mental acts in response
Significance distress or impairment

HOARDING DISORDER

Difficulty getting rid of stuff, regardless of its value and distress is even considered it
Results in accumulating possessions that congest living areas
Causes distress or impairment

Trichotillomania

Pulling out one’s hair (consistently/ recurrently)
Repeated attempts to decrease/stop this
Causes distress/impairment

EXCORIATION DISORDER

1. Recurrent skin-picking, resulting in skin lesions
2. Repeated attempts to decrease/stop
3. Causes distress/impairment

Trauma & Stress Disorders

• The precipitating event usually involves actual or threatened serious injury to self or others (generally unlike other anxiety disorders)
• During and immediately after trauma, many people become highly anxious and depressed. For some, feelings persist well after the trauma; these people may be experiencing trauma disorders

ADJUSTMENT DISORDER

Significant emotional or behavioral reaction to a stressor(s)
Examples: Divorce, starting school
NOT Bereavement
Symptoms must develop within 3 months of the stressor
Either distress beyond expected, or significant impairment of functioning
Case example(s)
College freshmen having a hard time in college (not making friends) exceed that typical freshmen would feel
A person’s first breakup - b/v meaning of it or their lack of emotional
A big divorce
* broad impairment

REACTIVE ATTACHMENT DISORDER

A pattern of emotionally withdrawn behavior toward caregivers (i.e., the child rarely seeks or responds to comfort when distressed)
Pervasive social/emotional issues, such as minimal responsiveness to others, limited positive affect, and/or unexplained irritability/sadness/fearfulness (needs 2 of
Proceeded by pathogenic care
Older than 9mos and manifest before age 5
Case example(s)
Abuse or neglect for kids → disruptive attachment disorders
The attachment system is shutdown → hard to make attachments, no attachment behaviors even in a safe environment

DISINHIBITED SOCIAL ENGAGEMENT DISORDER

The pattern of overly diffuse behavior toward strangers; 2+ of the following:
Missing reticence toward strangers
Overly familiar verbal/physical behavior
Lack of checking back with the caregiver
Willingness to go with unfamiliar adults with no hesitation
Not just impulsive, but socially disinhibited
Proceeded by pathogenic care
The child is at least 9 mos old
Case example(s)
This can happen with foster kids - bonding but in a diffuse way
Willingness to go off with a stranger

POST-TRAUMATIC STRESS DISORDER (P.1)

A history of having experienced, witnessed, or confronted event(s) involving death, serious injury, or threat to the physical integrity of self or others. The reaction of intense fear, helplessness, or horror produced by event
Event persistently re-experienced in at least one of the following ways:
Recurrent distressing recollections
Recurrent distressing dreams
Flashbacks, or a sense of reliving the experience
The distress caused by reminders of the event
Marked physiological reactions to reminders

POST-TRAUMATIC STRESS DISORDER (P.2)

Persistent avoidance of reminders of the event
Negative impact on thinking or mood (2+ sxs)
Marked symptoms of increased arousal (2+):
– Difficulty sleeping
– Irritability/anger
– Poor concentration
– Hypervigilance
– Exaggerated startle response
– Reckless or self-destructive behavior
• Distress or impairment, with sxs lasting
at least one month
* very fear-based and anxiety
* doesn’t fully capture racial trauma

ACUTE STRESS DISORDER

A history of having experienced, witnessed, or confronted event(s) involving death, serious injury, or threat to the physical integrity of self or others. The reaction of intense fear, helplessness, or horror produced by the event
9+ symptoms of intrusion, negative mood, dissociation, avoidance, and arousal (p. 280)
Lasts 3 days to 1 month after trauma
Distress or impairment

PROLONGED GRIEF DISORDER

Death of someone significant 12+ mos ago (6 mos in kids)
Since then, a “persistent grief response” with “intense yearning/longing” for deceased person and/or preoccupation with thoughts/memories
Plus, at least 3 symptoms, like identity disruption, disbelief, avoidance, numbness, intense pain and/or loneliness, or a difficult re-engaging/finding meaning in life
All of this occurs “nearly every day” for at least the last month
Either distress beyond expected, or significant impairment of functioning

Provisional

probably have the disorder
Stronger level of certainty

(R/O)

rule out = maybe
Not necessarily have evidence
Ask for more

“Ruled out”

= discarded
Looked at it and didn’t fit
No longer true

PANIC DISORDER

• Recurrent, unexpected Panic Attacks are Discrete periods of time with 4 or more symptoms that start immediately and peak w/in 10 mins
• Symptoms: pounding heart, sweating, shaking, shortness of breath, feeling of choking, chest pain, nausea, dizziness, derealization, fear of losing control or going crazy, fear of dying, numbness or tingling, chills or hot flashes
• Often mistaken for a heart attack
• 1+ mo. fear about having panic attacks or significantly changing behavior
• Terms: Social anxiety disorder, performance only - Social Anxiety, with Panic Attacks - Major Depressive Disorder with panic attacks - Panic Disorder = panic attacks + fear/avoidance

AGORAPHOBIA

• Marked fear or anxiety about 2+ of:
• Using public transportation
• Being in open spaces (e.g., parking lots, bridges)
• Being in enclosed spaces (e.g., shops, theaters)
• Standing in line or being in a crowd
• Being outside at home alone
• The person fears or avoids these places or situations b/c escape might be difficult (or embarrassing) or help may not be available
• Situations are then avoided or require a companion
• Fear is in excess of the actual situation and 6+ mos

SOCIAL ANXIETY DISORDER

• Fears of social or performance situations
  in which an individual may be “scrutinized” by others
• Fears being negatively evaluated
• Social situations provoke fear/anxiety and are avoided or endured with intense anxiety
• Again, out of proportion to the event
• Again, 6+ mos.
• Distress or impairment

GENERALIZED ANXIETY DISORDER

• 6+ months of persistent worrying about practically anything and everything
• Often called “free-floating” anxiety
• “Danger” not a factor
• A person feels they can’t control the worry
• At least 3 of: restlessness, being easily fatigued, difficulty concentrating or mind going blank, irritability, muscle tension, and/or sleep disturbance
• Case examples: Piglet from Winnie the Poo