Abnormal Psychology (Free Access)

ABNORMAL BEHAVIOR (Read: Abnormal Psychology An Integrative Approach, 8E)

  • Psychological disorders are behavioral, psychological, or biological dysfunctions that are unexpected in their cultural contextand associated with present distressand/or impairment in functioning, or increased risk of suffering, death, pain, or impairment (DSM, 2015)
  • Defining a psychopathology requires scientific study from different types of mental health professionals 
  • A diagnosis first begins with a description of current problems which are then understood as symptoms.
    • Symptoms help to segregated dysfunction from common distress
  • onset of disorders can be acute or chronic
    • acute onset is sudden and intense existence of symptoms associated with a disorder
    • chronic onset is a long drawn, not very intense but harmful existence of symptoms associated with a disorder

(Study Tip: Knowing one part of the two types of onset will help you remember the other one:
For the difference between acute and chronic, think of it as a-cute: as sudden and intense, similar to how you feel when you see a cute baby but in this case it’s for existence of symptoms of a disorder)

  • Causation
    • Historically most disorders have existed irrespective of time or culture
    • However, the reasons for the behaviour vary 
  • 3 traditions existed in explaining abnormal behavior
    • Supernatural: belief that paranormal activities were responsible for abnormal behaviour
    • Biological: belief that psychological disorders are an outcome of dysfunctional bodily systems
      • Not in homeostasis
      • Humoral theory claimed that optimum functioning was dependent on an individual having two much or too little of four key bodily fluids (humors)
        • Blood, phlegm, black bile, yellow bile
      • General paresis (syphilis) and the biological link with madness
    • Psychological: present understanding of psychological disorders
      • Patients should be treated with respect as one would any other patient in a normal environment
        • Major proponents:
        • Philippe Pinel, Jean-Baptiste Pussin, Benjamin Rush, Dorothea Dix – mental hygiene movement
  • Psychoanalytic Theory conceptualization (Read: Personality Psychology)
    • Unconscious repressed anxiety causing memories lead to abnormal behaviour
      • Overuse of defensive mechanisms
      • Defense mechanisms are attempts made by the ego to manage the anxiety created by the conflict of id and superego
  • Humanistic Theory: the belief that abnormal behaviour is a result of lack of positivity in the clients life and lack of understanding from their immediate environment
    • Intrinsic human goodness
    • Striving for self-actualization
      • Person-centered therapy: Carl Rogers
      • Hierarchy of Needs: Abraham Maslow
  • The Behavioral Model (Read: Personality Psychology
    • Abnormal behaviour is a result of learnt behaviour either by classical conditioning, operant conditioning, or social learning theory
    • Classical conditioning: Ivan Pavlov
    • Operant Conditioning: B. F. Skinner
    • Social learning theory: Alfred Bandura
  • The Scientific Method and an Integrative Approach: understand abnormal behaviour from an eclectic point of view where many biological, psychological, social factors affect the individual resulting in maladaptive behaviour
  • The Clinical Interview is the main source of getting information from the client. It includes asking them about the present situation, past behaviour, history of the issues presented, family history, and a mental status exam
  • Mental status exam is the attempt to see the current disposition of the client. It is assessed by the following aspects:
    • Appearance and behavior
    • Thought processes
    • Mood and affect
    • Intellectual functioning
    • Sensorium
  • (Study Tip:  ATM-IS)
  • Diagnostic classification is important as it helps classifying the varied behaviours into specific parts
    • It is essential for all sciences
  • Idiographic strategy is the method of classifying based on extreme or unique aspects of individual’s personality, and culture
  • (Study Tip: idio for idiots who are unique or not common)
  • Nomothetic strategy is the method of classifying based on identifying a disorder and its patterns
  • Terminology of classification systems
    • Taxonomy is the scientific term for classification
    • Nosology is the taxonomy used for psychological or medical phenomena
    • Nomenclature are the labels attributed to the nosological labels (e.g., “mood disorder” “anxiety disorders”)
  • Classification approaches
    • Classical (or pure) categorical approach creating categories as rigid and unchanging categories
    • Dimensional approach look to create categories along a range of behaviour 
    • Prototypical approach is a combination of the two where labels are given but along a continuum 
  • Diagnostic and Statistical Manual of Mental Disorders (DSM) (Read: (DSM-5: A Comprehensive Overview)
    • Updated every 10-20 years
    • Current edition (released May 2013): DSM-5
    • Previous edition called DSM-IV-TR
  • International Classification of Diseases (ICD-10)
    • By the World Health Organization (WHO)
  • Problems with classification
    • Creates stigma and labels
    • Labels usually have negative connotations and may make patients less likely to seek treatment

Anxiety Disorders

  • Anxiety refers to a general feeling of apprehension about possible dangers which is different from a disorder.
  • Anxiety disorders are a group of disorders that include disorders that share features of excessive fear and anxiety and related behavioral disturbances.
  • The anxiety disorders differ from one another in the types of objects or situations that induce fear, anxiety, or avoidance behavior, and the associated cognitive ideation.
  • It is also important to differentiate Fear & Anxiety
  • Anxiety is apprehension over an anticipated problem, a future event, whereas fear is a reaction to immediate danger.
    • Thus, a person facing a bear, experiences fear, whereas a college student concerned about the possibility of unemployment after graduation experiences anxiety.
  • When the source of danger is obvious, the experienced emotions is called fear. Anxiety is a result of the anticipation of some dreadful future event taking place which is not entirely predictable from our actual circumstances leading to an internal uncomfortable feeling.
  • Anxiety has some positives as well:
    • It is adaptive in helping us notice and plan for future threats,
    • To increase our preparedness,
    • To help people avoid potentially dangerous situations, and
    • To think through potential problems before they happen.
  • Anxiety provides a classic example of an inverted U-shaped curve with performance—an absence of anxiety is a problem, a little anxiety is adaptive, and a lot of anxiety is detrimental.

Anxiety Disorders

  • An anxiety disorder has an unrealistic, irrational fear or anxiety of disabling intensity at its core & also as its principal & most obvious manifestation.

Types of Anxiety Disorders according to DSM 5

Specific Phobia

  • The term phobia refers to excessive fear of a specific object, circumstance, or situation.
    • A specific phobia is a strong, persisting fear of an object or situation.
    • The diagnosis of specific phobia requires the development of intense anxiety when exposed to the feared object.
    • Some types of phobias (not diagnosed as such)
Acrophobia Fear of heights
Agoraphobia Fear of open places
Ailurophobia Fear of cats
Hydrophobia Fear of water
Claustrophobia Fear of closed places
Cynophobia Fear of dogs
Mysophobia Fear of dirt/germs
Pyrophobia Fear of fire
  • DSM V Criteria for specific phobia

A. Marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood).

B. The phobic object or situation almost always provokes immediate fear or anxiety.

C. The phobic object or situation is actively avoided or endured with intense fear or anxiety.

D. The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the socio-cultural context.

E. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.

F. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

G. The disturbance is not better explained by the symptoms of another mental disorder, including fear, anxiety, and avoidance of situations associated with panic-like symptoms or other incapacitating symptoms (as in agoraphobia): objects or situations related to obsessions (as in obsessive-compulsive disorder); reminders of traumatic events (as in

posttraumatic stress disorder); separation from home or attachment figures (as in separation anxiety disorder); or social situations (as in social anxiety disorder).

  • Phobic behavior tends to be reinforced by the reduction in anxiety that occurs each time a feared situation is avoided.
  • Phobias  may be maintained by secondary gains (benefits derived from being disabled) such as increased attention, sympathy and some control over the behavior of others; 
  • Blood- injection-injury phobia- The afflicted person shows a unique physiological response at the sight of blood or injury.
    • They show an initial acceleration in heart rate and blood pressure followed by a dramatic drop.
    • This is accompanied by nausea, dizziness, and fainting.
  • Causal factors
  • Genetic Factors: Specific phobia tends to run in families.
    • The blood-injection-injury type has a particularly high familial tendency.
    • Genetic & temperamental causal factors: A moderate genetic contribution exists.
      • Personality or temperamental variables have a role to play in building fear and anxiety.
      • Behaviorally inhibited children (e.g.excessively timid, shy) at 21 months of age were at higher risk for the development of multiple specific phobias at 7 to 8 years of age.
      • Preparedness & the nonrandom distribution:  Primates & humans may be prepared biologically to rapidly associate certain kinds of objects such as snakes, spiders, water & enclosed places- with aversive events.
      • Fear could be conditioned more effectively to fear-relevant stimuli (e.g. snakes & spiders) than to fear irrelevant stimuli (e.g. flowers & mushrooms).
        • Evolutionary factors may be responsible for this association.
      • Treatment
        • Exposure therapy- controlled exposure to the stimuli or situations that elicit phobic fear
        • Participant modeling-therapist calmly models ways of interacting with the phobic stimulus or situation
        • Virtual reality environments stimulate certain kinds of phobic situations, such as heights as places to conduct exposure treatment.
  • Psychosocial causal factors
    • Psychodynamic: phobias represent a defense against anxiety that stems from repressed impulses from the id.
      • Because it is dangerous to know the repressed id impulse, the anxiety is displaced on to some external object or situation that has some symbolic relationship to the real object of the anxiety.
    • Learning:  classical conditioning accounts for the acquisition of irrational fears & phobias. The fear response can be conditioned to previously neutral stimuli when they are paired with traumatic events.
      • Once acquired, phobic fears would generalize to other similar objects or situations.
      • Fears can be transmitted from one person to another through a process of vicarious or observational learning.
      • Merely observing the fear of another one in a given situation may cause the observer to acquire a fear.
      • Watching a non-fearful person undergoing a frightening experience can also lead to vicarious conditioning.
  • Individual differences in learning: Some individuals due to life experiences may have more risk factors which would make them more vulnerable to phobias than others whereas other’s experiences may serve as protective factors for the development of phobias.
  • Usually, an experience of an inescapable & uncontrollable event from which one can’t escape conditions fears much more painfully than experiencing the same intensity of trauma that one can escape from or to some external control.

Social anxiety disorder (Social phobia)

  • Clinical Picture:
  • Persistent, unrealistically intense fear of social situations that might involve being scrutinized by, or even just exposed to, unfamiliar people.
  • Persons with a social anxiety disorder are fearful of embarrassing themselves in social situations (i.e., social gatherings, oral presentations, meeting new people).
  • They may have specific fears about performing specific activities such as eating or speaking in front of others, or they may experience a vague, nonspecific fear of “embarrassing oneself”.
  • Fear of negative evaluation by others is the hallmark.
  • Two subtypes of social phobia- specific & generalized.


A. Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions (e.g., having a conversation, meeting unfamiliar people), being observed (e.g., eating or drinking), and performing in front of others (e.g., giving a speech).

B. The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating or embarrassing: will lead to rejection or offend others).

C. Social situations almost always provoke fear or anxiety.

  • Diagnostic criteria

D.The social situations are avoided or endured with intense fear or anxiety.

E. The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the socio-cultural context.

F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.

G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

  • Diagnostic criteria

H. The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

I. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder.

J. If another medical condition (e.g., Parkinson’s disease, obesity, disfigurement from bums or injury) is present, the fear, anxiety, or avoidance is unrelated or is excessive

  • Because of their fears, they avoid situations.
  • Individuals with  generalized social phobia have significant fears of most social situations(both public performance situations & situations requiring social interactions)
  • They often share a diagnosis of avoidant personality disorders.


  • Psychosocial causal factors
    • Learning: It originates out of vicarious or direct classical conditioning e.g. being criticized in front of a group
    • Generalized social phobia: This occurs because of parents who are socially isolated & who devalued sociability, therefore leading to providing ample opportunity for vicarious learning.
    • Social phobias in an evolutionary context
      • Social phobias are a byproduct of dominance hierarchies among animals like primates.
      • Dominance hierarchies are established through aggressive encounters between members of a group and any defeated individual typically displays fear and submissive behavior and only rarely attempts to escape the situation.
  • Genetic and temperamental factors
    • There is a moderate genetic contribution to social phobia.
    • Behaviorally inhibited infants who are shy & avoidant are more likely to become fearful during childhood and by adolescence, show increased risk of developing social phobia.
    • Perceptions of uncontrollability &unpredictability lead to more socially anxious or phobic behaviour.
    • Socially anxious individuals have a diminished sense of personal control over events in their lives.
    • It may develop at least in part as a function of having been raised in families with overprotective (sometimes rejecting)parents.
  • Treatment
    • Behavioural and cognitive behavioural therapy is effective
      • Clients are helped to identify their negative automatic thoughts & directed to change inner thoughts & beliefs through logical reanalysis
    • Antidepressants are also used
  • Panic disorder
  • DSM V Diagnostic criteria
  • Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur;
  • Note: The abrupt surge can occur from a calm state or an anxious state.
  • 1. Palpitations, pounding heart, or accelerated heart rate.
  • 2. Sweating.
  • 3. Trembling or shaking.
  • 4. Sensations of shortness of breath or smothering.
  • 5. Feelings of choking.
  • 6. Chest pain or discomfort.
  • 7. Nausea or abdominal distress.
  • 8. Feeling dizzy, unsteady, light-headed, or faint.
  • 9. Chills or heat sensations.
  • 10. Paresthesias (numbness or tingling sensations).
  • 11. Derealization (feelings of unreality) or depersonalization (being detached from oneself).
  • 12. Fear of losing control or “going crazy.”
  • 13. Fear of dying.
  • Panic attacks are unexpected.
  • Diagnostic criteria

B. At least one of the attacks has been followed by 1 month (or more) of one or both of the following:

1. Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, “going crazy”).

2. A significant maladaptive change in behavior related to the attacks (e.g., behaviors designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations).

C. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism, cardiopulmonary disorders).

D. The disturbance is not better explained by another mental disorder (e.g., the panic attacks do not occur only in response to feared social situations, as in social anxiety disorder: in response to circumscribed phobic objects or situations, as in specific phobia: in response to obsessions, as in obsessive-compulsive disorder: in response to reminders of traumatic events, as in posttraumatic stress disorder: or in response to separation from attachment figures, as in separation anxiety disorder).

Biological causal factors

  • Genetic factors: panic disorder has a moderately heritable component.
  • Panic provocation agents: Individuals with panic disorder are more likely to experience panic attacks when they are exposed to various biologically challenging procedures than are normal people
    • e.g.; infusions of sodium lactate, inhaling co2 & ingesting caffeine produce panic attacks in them.
  • Panic & the brain: abnormal norepinephrine activity in the locus coeruleus in the brain stem may play a crucial causal role in a panic attack
    • Noradrenergic activity in certain brain areas can stimulate cardiovascular symptoms associated with panic.
  • Amygdala: Panic is likely to develop in people who have abnormally sensitive fear networks that get activated too readily to be adaptive.
  • Hippocampus: The anticipatory anxiety that people develop about having another panic attack is thought to arise from activity in the hippocampus which is involved in the learning of emotional responses.
  • A learned response such as Phobic avoidance may involve activation of the hippocampus.
  • Behavioral & cognitive causal factors
    • Panic attacks occur through a process of interoceptive conditioning.
    • Interoceptive conditioning is the association of internal bodily sensations that have been already been associated with a panic attack, will acquire the capacity to provoke panic themselves.
      • e.g.; heart palpitations may occur at the beginning of a full-blown attack and the individual may think of it as a predictor of an incoming attack, they may themselves acquire the capacity to provoke panic attacks.
    • Beck & Emery proposed a cognitive model of panic: Any kind of perceived threat may lead to apprehension or worry which is accompanied by various bodily sensations.
      • If a person then catastrophizes about the meaning of his bodily sensations, this will raise the level of perceived threat, thus creating more apprehension & worry, as well as more physical symptoms, which fuel further catastrophic thoughts.
      • This vicious circle can result in a panic attack.
      • Sometimes, the initial physical sensations need not arise from the perceived threat but may come from other sources (exercise, anger, psychoactive drugs, etc.)
    • Learning theory of panic is different from cognitive theory because according to it, it would be only those with panic disorder for whom the cues might serve as interoceptive conditioning, which can trigger anxiety & panic because of their associations with panic.
    • The cognitive model places importance on the meaning that people attach to their bodily sensations, they will experience panic only if they make catastrophic interpretations of certain bodily sensations.
  • Anxiety sensitivity & perceived control
    • People who have high levels of anxiety sensitivity are more prone to developing panic attacks & panic disorder.
    • Anxiety sensitivity is a trait like a belief that certain bodily symptoms may have harmful consequences.
    • Having a sense of perceived control.
  • Safety behaviors & the persistence of panic
    • People with panic disorder frequently engage in safety behaviors (such as breathing slowly) before or during an attack.
      • They then mistakenly tend to attribute the lack of catastrophe to their having engaged in this safety behavior rather than to the idea that panic attacks do not lead to heart attacks.
  • Cognitive biases &the maintenance of panic
    • People with panic disorder are biased in the way they process threatening information.
    • They not only interpret ambiguous bodily sensations as threatening but also interpret other ambiguous bodily sensations as threatening.
  • These people’s attention was automatically drawn to threatening information in their environment such as words that represent things they fear.
  • These biases are certainly likely to help
  • Treatment
  • Antianxiety drugs & antidepressants are helpful
  • Exposure based treatments are also effective
  • Interoceptive exposure- deliberate exposure to feared internal sensations
  • Clients are asked to do exercises that bring on the physical sensations they fear.

Generalized Anxiety Disorder

  • It involves anxiety & worries about many different aspects of life (including minor events) & it becomes chronic, excessive & unreasonable.
  • DSM V Criteria
  • A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work, home, cleanliness, order or school performance).
  • B. The individual finds it difficult to control the worry.
  • C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months);

Anxiety & worry associated with 3 or more of the following 6 symptoms for more days than not:

  1. Restlessness or feeling keyed up.
  2. Being easily fatigued.
  3. Difficulty concentrating.
  4. Irritability.
  5. Muscle tension.
  6. Sleep disturbance.
  7. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  8. E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism).
  9. F. The disturbance is not better explained by another mental disorder (e.g., anxiety or worry about having panic attacks in panic disorder, negative evaluation in social anxiety disorder [social phobia], contamination or other obsessions in obsessive-compulsive disorder, separation from attachment figures in separation anxiety disorder, reminders of traumatic events in posttraumatic stress disorder, gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived appearance flaws in body dysmorphic disorder, having a serious illness in illness anxiety disorder, or the content of delusional beliefs in schizophrenia or delusional disorder).

Clinical Picture

  • People with GAD live in a relatively future-oriented mood state of anxious apprehension, chronic tension, worry & diffuse uneasiness.
  • They show marked vigilance for possible signs of threat in the environment and frequently engage in subtle avoidance activities such as procrastination, checking, or calling a loved one frequently to see if he or she is safe.
  • Their anxious apprehension makes them ready to deal with upcoming negative events.
  • They have difficulty making decisions, but if they have managed to make a decision, they worry endlessly over possible errors.
  • They are continuously upset, uneasy & discouraged.
  • They fail to escape the illusory world created in their thoughts and images and rarely experience the present moment that possesses the potential to bring them joy (Behar & Borkovec, 2006).

Causal factors

  • Psychoanalysis: GAD results from an unconscious conflict between the id & impulse that is not adequately dealt with because the person’s defense mechanisms have either broken down or have never developed.
    • It was primarily sexual & aggressive impulses that had been either blocked from expression.
  • The role of unpredictable & uncontrollable events: people with GAD may have a history of experiencing many important events in their lives as unpredictable & uncomfortable.
    • E.g.; having a boss who has unpredictable bad moods.
  • Safety signals: Their intolerance for uncertainty as well as their tension & hyper-vigilance stems from their lacking safety signals in their environment.
    • Without such safety signals such as knowing when their boss will or will not be angry with them, they may never be able to relax & feel safe.
    • Early experiences with control & mastery immunize the individual against the harmful effects of exposure to stressful situations & against the development of GAD.
    • Parent’s responsiveness to their children’s needs directly influences their children’s developing sense of mastery.
    • Parents of anxious children have an intrusive, over-controlling parental style, which promotes children’s anxious behavior by making them think that the world is an unsafe place and they require protection and have little control themselves
  • The reinforcing properties of worry
    • Superstitious avoidance of catastrophe (worrying makes it less likely that the feared event will occur).
    • Avoidance of deeper emotional topics (worrying about most of the things I worry about is a way to distract myself from worrying about even more emotional things, things that I do not want to think about)
    • Coping & preparation(worrying about a predicted negative event helps me to prepare for its occurrence)
    • When they worry, emotional & physiological responding are suppressed, & this serves to reinforce the process of worry.
  • The negative consequences of worry: worry can lead to a greater sense of danger & anxiety because of all the possible catastrophic outcomes that the person envisions.
    • People who worry tend to have more negative intrusive thoughts.
    • Attempts to control thoughts and worry paradoxically lead to the increased experience of intrusive thoughts and enhanced perception of being unable to control them.
  • Cognitive biases for threatening information: they process threatening information in a biased way.
  • Attentional bias plays a causal role in anxiety.
    • Anxious people think that bad things are likely to happen in the future, & they tend to interpret ambiguous information in a threatening way.
  • Biological causal factors: there is a modest heritability in GAD
    • Functional deficiency of GABA: Highly anxious people have a kind of functional deficiency in GABA, gamma-aminobutyric acid, a neurotransmitter that plays an important role in the way the brain inhibits anxiety in stressful situations.
  • The corticotrophin-releasing hormone system & anxiety: An anxiety-producing hormone called CRH has been strongly implicated as playing an important role in GAD.
  • The brain areas & neurotransmitters that are strongly implicated in panic are the amygdala, norepinephrine & serotonin, but in anxiety, it is the limbic system, GABA & CRH.
  • Neurological differences between anxiety & panic: Fear & panic involve activation of the flight or fight response whereas GAD or anxious apprehension is a more diffuse emotional state involving arousal & preparation for possible impending threat.


  • Antianxiety& antidepressant drugs are useful
  • CBT- applied muscle relaxation & cognitive restructuring techniques

Obsessive compulsive and related disorders

It includes obsessive-compulsive disorder (OCD), body dysmorphic disorder, hoarding disorder, trichotillomania (hairpulling disorder), excoriation (skin-picking) disorder, substance/medication-induced obsessive- compulsive and related disorder

Obsessive Compulsive Disorder

  • OCD is characterized by the presence of obsessions and compulsions.
  • Obsessionsare recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted, whereas
  • Compulsionsare repetitive behaviors or mental acts that an individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.
    • Obsessive thoughts are from within/internal the person rather than from outside/external

Obsessive-compulsive disorder


  • Presence of obsessions, compulsions, or both:
  • Obsessions are defined by (1) and (2):
  • 1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.
  • 2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion).
  • Types of Compulsions are defined by (1) and (2):
  • 1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.
  • 2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive.
  • The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.
  • D. The disturbance is not better explained by the symptoms of another mental disorder (e.g., excessive worries, as in generalized anxiety disorder; preoccupation with appearance, as in body dysmorphic disorder; difficulty discarding or parting with possessions, as in hoarding disorder; hair pulling, as in trichotillomania [hair-pulling disorder]; skin picking, as in excoriation

disorder; stereotypies, as in stereotypic movement disorder; ritualized eating behavior, as in eating disorders; preoccupation with substances or gambling, as in substance-related and addictive disorders; preoccupation with having an illness, as in illness anxiety disorder; sexual urges or fantasies as in paraphilic disorders; impulses, as in disruptive, impulse-control, and conduct disorders; guilty ruminations, as in major depressive disorder; thought insertion or delusional preoccupations, as in schizophrenia spectrum and other psychotic disorders; or repetitive patterns of behavior, as in autism spectrum disorder).

  • Many obsessive thoughts involve contamination fears, fears of harming oneself or others, concerns about or need for symmetry, sexual obsessions, obsessions concerning religion or aggression and pathological doubt.
  • Types of compulsions: people with OCD feel compelled to perform acts repeatedly that seem pointless & absurd even to them & that they in some sense do not want to perform.
  • 5 types of compulsive acts: cleaning, checking, repeating, ordering/arranging & counting & many people show multiple kinds of rituals.
  • The performance of the compulsive acts brings a feeling of reduced tension & satisfaction as well as sense of control. But this anxiety relief is fleeting, & repeat the actions over & over.
  • Consistent characteristics:
  • Anxiety is the affective symptom.
  • Compulsions usually reduce the anxiety to some degree, at least in the short term.
  • Nearly all people afflicted with OCD fear that something terrible will happen to themselves or others for which they will be responsible.


  • Psychosocial causal factors
    • Learning: In line with classical conditioning some neutral stimuli may become associated with frightening thoughts or experiences that cause anxiety.
      • E.g. walking without gloves may create a fear of contamination
      • Once having made this association, the person may discover that the anxiety produced by touching can be reduced by hand washing.
      • Hand washing would then serve as an avoidant and such avoidant responses are then reinforced and maintained making them extremely resistant to extinction.
  • OCD & preparedness: thoughts about dirt & contamination have deep evolutionary roots.
  • Cognitive causal factors
    • The effects of attempting to suppress obsessive thoughts: When attempt to suppress unwanted thoughts is made, people experience a paradoxical increase in those thoughts later.
    • If thought suppression occurs, during a negative mood, a connection is produced between the thought & the negative mood.
    • When the negative mood occurred again later, the thought was more easily experienced, or when the thought was later experienced, the mood returned.
    • Appraisals of responsibility for intrusive thoughts: people with OCD have an exaggerated sense of responsibility, possibly due to parenting in early childhood because of excessive criticism.
    • Cognitive biases & distortions
      • Selective attention is paid to material that is related to their obsessive concerns.
  • Biological causal factors
    • Genetic influences: Monozygotic twins have a higher likelihood of having the disorder compared dizygotic twin.
    • First degree relatives have a higher rate of suffering from OCD
    • A form of OCD that often starts in childhood characterized by chronic motor tics, linked to Tourette’s syndrome is suspected to have a genetic basis.
  • OCD and the brain:
    • Increased serotonin activity & increased sensitivity of some brain structures to serotonin are involved in OCD symptoms.
    • Abnormalities in the basal ganglia.
  • The orbital frontal cortex, the cingulate cortex and caudate nucleus are extremely active.


  • Behavioral and cognitive behavioral;
    • Exposure and response prevention

Post-Traumatic Stress Disorder

  • Truama and stressor related disorders include disorders in which exposure to a traumatic or stressful event is listed explicitly as a diagnostic criterion.
    • These include reactive attachment disorder, disinhibited social engagement disorder, posttraumatic stress disorder (PTSD), acute stress disorder, and adjustment disorders.
  • Criteria for PTSD
  • A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:
  • 1. Directly experiencing the traumatic event(s).
  • 2. Witnessing, in person, the event(s) as it occurred to others.
  • 3. Learning that the traumatic event(s) occurred to  close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.
  • Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains: police officers repeatedly exposed to details of child abuse).
  • B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:
  • Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).
  • Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s).
  • Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.)
  • Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
  • Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
  • C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following:
  • Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
  • Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

1. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).

2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” ‘The world is completely dangerous,” “My whole nervous system is permanently ruined”).

3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others.

4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).

5. Markedly diminished interest or participation in significant activities.

6. Feelings of detachment or estrangement from others.

7. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).

  • Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
  • 1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects.
  • 2. Reckless or self-destructive behavior.
  • 3. Hypervigilance.
  • 4. Exaggerated startle response.
  • 5. Problems with concentration.
  • 6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).
  • F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.
    • G. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
    • H. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.
  • The symptoms are grouped into 4 main areas and concern the following:
  • Intrusion: recurrent re-experiencing of the traumatic event through nightmares, intrusive images, and physiological reactivity to reminders of the trauma.
  • Avoidance: efforts to avoid thoughts, feelings, or readiness of the trauma.
  • Negative alterations in cognitions and mood: this includes such symptoms as feelings of detachment as well as negative emotional states such as shame or anger, or distorted blame of oneself or others.
  • Arousal and reactivity: hypervigilance, excessive response when startled, aggression and reckless behavior.
  • The Trauma of Military Combat
    • Combat brings constant fear, unpredictability, many uncontrollable circumstances, and the necessity of killing test an individuals coping methods. While the training allows the soldier to adjust to these gruesome times, when they return in peace time, these repressed issues resurface as flashback and are difficult to cope with leading to PTSD
    • Long term effects: Soldiers who have experienced combat exhaustion suffered long term damage to their adaptive capabilities, in some cases, complicated by memories of killing enemy soldiers or civilians as well as feelings tinged with guilt & anxiety.
  • Causal factors in post- traumatic stress
    • Higher levels of developing PTSD are associated with: Gender (female), higher levels of neuroticism, low levels of social support, having preexisting problems with depression and anxiety, and substance abuse.
    • Individual risk factors: factors increase the likelihood of being exposed to trauma include being male, having less than a college education, having had conduct problems in childhood, having a family history of psychiatric disorder, and scoring high on measures of extraversion and neuroticism.
    • Protective factor: Having a higher IQ
    • Conditioned fear- the fear associated with the traumatic experience- appears to be a causal factor.


  • CBT with focus on readjustment
  • Behavioural therapy with deconditioning
  • Group therapy with other people suffering from PTSD are helpful as well
    • Especially for combat veterans

Mood Disorders and Suicide

  • Mood disorders = gross deviations in mood
  • Mood Disorders:  A group of psychological disorders characterised by disruption of mood for longer periods of time that causes clinically significant impairment and distress. The two basic symptoms patterns in mood disorders are depression and mania, however, mixed states are also possible.
  • Composed of different types of mood “episodes”
    • Periods of depressed or elevated mood lasting days or weeks, including:
      • Major depressive episodes
      • Manic episodes
      • Hypomanic episodes

Major Depressive Episode

Depressive episode is a distinct period lasting for at least 2 weeks and is characterized by:

  • Depressed mood: sadness of mood or loss of interest and/or pleasure (Anhedonia) in almost all activities (i.e. pervasive sadness), which is present throughout the day (persistent sadness).
  • Depressive ideation/cognition: Sadness of mood is accompanied by three common types of depressive ideas – Hopelessness, Helplessness, Worthlessness
  • Other features are – difficulty in concentrating, indecisiveness, slowed thinking, subjective poor thinking, lack of energy and initiative and suicidal ideation.
  • Physical symptoms of aches and pains, heaviness of head, fatigue and lack of energy are reported.
  • May be accompanied by insomnia, reduced weight, loss of appetite or the exact opposite.

DSM-5 Criteria: Major Depressive Episode

  • Criteria
  • A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

Note: Do not include symptoms that are clearly due to a general medical condition or mood-incongruent delusions or hallucinations.

1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g.,

appears tearful). Note: in children and adolescents can be irritable mood.

2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)

3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly

every day. Note: in children, consider failure to make expected weight gains

  • DSM-5 Criteria: Major Depressive Episode,  continued

4. Insomnia or hypersomnia nearly every day

5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)

6. Fatigue or loss of energy nearly every day

7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)

8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)

9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

C. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).

From American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC

Manic Episode

  • A manic episode is a distinct period of an abnormally and persistently elevated, expansive, or irritable mood lasting for at least 1 week. The elevated mood is euphoric and often infectious and can even cause a countertransferential denial of illness by an inexperienced clinician.
    • Although uninvolved persons may not recognize the unusual nature of a patient’s mood, those who know the patient recognize it as abnormal.
  • Examples of symptoms:
    • Inflated self-esteem, decreased need for sleep, excessive talkativeness, flight of ideas or sense that thoughts are racing, delusions of grandeur, easy distractibility, increase in goal-directed activity or psychomotor agitation, excessive involvement in pleasurable but risky behaviors, reduced sleep, increase in appetite followed by reduction. Some psychotic features may be present as well
  • Impairment in normal functioning
  • DSM-5 Criteria: Manic Episode
  • Criteria

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary).

B. During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior:

1. Inflated self-esteem or grandiosity

2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)

3. More talkative than usual or pressure to keep talking

4. Flight of ideas or subjective experience that thoughts are racing

5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.

6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (e.g., purposeless non-goal-directed activity).

7. Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

C. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

D. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or to another general medical condition.

Note: A full manic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence of a manic episode and, therefore, a bipolar I diagnosis.

From American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC.

Hypomanic episode

  • Shorter, less severe version of manic episodes
    • Last at least four days
    • Have fewer and milder symptoms
    • Associated with less impairment than a manic episode (e.g., less risky behavior)
    • May not be problematic in and of itself, but usually occurs in the context of a more problematic mood disorder

 Mixed features= term for a mood episode with some elements reflecting the opposite attributes of mood

  • Example: Depressive episode with some manic features
    • Example: Manic episode with some depressed/anxious features

The Structure of Mood Disorders

  • Unipolar mood disorder: Only one extreme of mood is experienced
    • E.g., only depression or only mania
    • Depression alone is much more common than mania alone
  • Bipolar mood disorder: Both depressed and elevated moods are experienced
    • E.g., some depressive episodes and some manic or hypomanic episodes

DSM-5 (Unipolar) Depressive Disorders

  • Major depressive disorder
    • Persistent depressive disorder
      • New to DSM-5:
      • Premenstrual dysphoric disorder
      • Disruptive mood dysregulation disorder
  • Major Depressive Disorder
  • Clinical features
    • One or more major depressive episodes separated by periods of remission
    • Single episode – highly unusual
    • Recurrent episodes – more common

Major Depressive Disorder

  • Criteria

A. At least one major depressive episode

B. The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders.

C. There has never been a manic episode or hypomanic episode. Note: This exclusion does not apply if all of the manic-like or hypomanic-like episodes are substance induced or are attributable to the direct physiological effects of another medical condition.

Specify the clinical status and/or features of the current or most recent major depressive episode:

Single episode or recurrent episode; Mild, moderate, severe; With anxious distress; With mixed features; With melancholic features; With atypical features; With mood-congruent psychotic features; With mood-incongruent psychotic features; With catatonia; With peripartum onset; With seasonal pattern (recurrent episode only); In partial remission, in full remission

From American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC.

DSM-5 Bipolar Disorders

  • Bipolar I disorder
  • Criteria
  • Alternations between major depressive episodes and manic episodes
  • DSM-5 Criteria: Bipolar II Disorder
  • Criteria

A. Criteria have been met for at least one hypomanic episode and at least one major depressive episode.

Criteria for a hypomanic episode are identical to those for a manic episode, with the following distinctions: 1) Minimum duration is 4 days; 2) Although the episode represents a definite change in functioning, it is not severe enough to cause marked social or occupational impairment or hospitalization; 3) There are no psychotic features.

B. There has never been a manic episode.

C. The occurrence of the hypomanic episode(s) and major depressive episode(s) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.

D. The symptoms of depression or the unpredictability caused by frequent alternation between periods of depression and hypomania causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify current or most recent episode:

  • Hypomanic: If currently (or most recently) in a hypomanic episode
  • Depressed: If currently (or most recently) in a major depressive episode

Specify if: With anxious distress; With mixed features; With rapid cycling; With mood-congruent psychotic features; With mood-incongruent psychotic features; With catatonia; With peripartum onset; With seasonal pattern

  • Specify course if full criteria for a mood episode are not currently met:
    • In full remission, in partial remission
  • Specify severity if full criteria for a mood episode are currently met: Mild, moderate, severe

From American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC.

Cyclothymic Disorder

  • Chronic version of bipolar disorder
    • Alternating between periods of mild depressive symptoms and mild hypomanic symptoms
      • Episodes do not meet criteria for full major depressive episode, full hypomanic episode or full manic episode
    • Hypomanic or depressive mood states may persist for long periods
    • Must last for at least two years (one year for children and adolescents)

DSM-5 Criteria: Cyclothymic Disorder

A. For at least 2 years (at least 1 year in children and adolescents) there have been numerous periods with hypomanic symptoms that do not meet criteria for a hypomanic episode and numerous periods with depressive symptoms that do not meet criteria for a major depressive episode.

B. During the above 2-year period (1 year in children and adolescents), the hypomanic and depressive periods have been present for at least half the time and the individual has not been without the symptoms for more than 2 months at a time.

C. Criteria for a major depressive, manic, or hypomanic episode have never been met.

D. The symptoms in criterion A are not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.

E. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism).

F. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify if:

  • With anxious distress

From American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC.

  • Diagnostic Specifiers for Bipolar Disorders
    • All of the specifiers for depressive disorders may also apply to bipolar disorders
    • Additional specifer unique to bipolar disorders: Rapid cycling specifier
      • Moving quickly in and out of mania and depression
      • Individual experiences at least four manic or depressive episodes within a year
      • Occurs in between 20-50% of cases
      • Associated with greater severity

Persistent Depressive Disorder

  • This disorder is a consolidation of DSM IV defined chronic major depressive disorder and dysthymic disorder.
  • The essential feature of persistent depressive disorder (dysthymia) is a depressed mood that occurs for most of the day, for more days than not, for at least 2 years or 1 year for children & adolescents and any symptom free intervals last no longer than 2 months.
    • Symptoms can persist unchanged over long periods (≥ 20 years)
      • As these symptoms become a part of the individuals day to day experience particularly in the case of early onset they may not be reported unless directly prompted
    • May include periods of more severe major depressive symptoms
      • Major depressive symptoms may be intermittent or last for the majority or entirety of the time period
      • Major depression may precede persistent depressive disorder and MDE may occur during persistent depressive disorder.


  • Types of PDD
    • Mild depressive symptoms without any major depressive episodes (“with pure dysthymic syndrome”)
    • Mild depressive symptoms with additional major depressive episodes occurring intermittently (previously called “double depression”)
    • Major depressive episode lasting 2+ years (“with persistent major depressive episode”
    • Possible Course of Depressive Disorders
  • Diagnostic Specifiers for Depressive Disorders
    • Specifier: Additional diagnostic label used by clinicians to convey extra information about symptoms
    • Specifiers are not mandatory; only assigned if appropriate
    • Psychotic features specifier
      • Major depressive episodes which also include some psychotic features
        • Hallucinations: Sensory experience in the absence of sensory input
        • Delusions: Strongly held inaccurate beliefs
    • Anxious distress specifier
      • Depression is accompanied by several significant symptoms of anxiety
      • Predicts poorer outcome
    • Mixed features specifier
      • Depressive episodes which also include everal manic symptoms
    • Melancholic features specifier
      • Major depressive episode accompanied by additional severe symptoms such as early morning awakenings, lack of reactivity to positive stimuli
    • Catatonic features specifier:
      • Extremely rare muscular symptoms such as remaining in a still stupor, “waxy” limbs that remain in place when manipulated, repetitive or purposeless movement
    • Atypical features specifier:
      • Presence of several symptoms less common in depression, including oversleeping and overeating
    • Peripartum onset specifier:
      • Depression occurring around the time of giving birth
    • Seasonal pattern specifier: Depression occurring primarily in certain seasons (usually winter)
      • Sometimes called seasonal affective disorder.
      • May be related to seasonal changes in melatonin
      • May be treated effectively with light therapy
  • Onset and Duration of Depressive Disorders
    • Rare in childhood
    • Risk increases in adolescence and young adulthood
    • Mean age of onset = 30
    • Earlier onset of persistent depression associated with worse outcome
    • Depressive episodes are variable in length
      • Usually last several months untreated, but may last several years

From Grief to Depression

  • In previous editions of the DSM, depression could not be diagnosed during periods of mourning
  • Now recognized that major depression may occur as part of the grieving process
    • Acute grief: Occurs immediately after loss
    • Integrated grief: Eventual coming to terms with meaning of the loss
    • Complicated grief: Persistent acute grief and inability to come to terms with loss

Other Depressive Disorders

Premenstrual Dysphoric Disorder

  • Significant depressive symptoms occurring prior to menses during the majority of cycles, leading to distress or impairment
    • Controversial diagnosis
      • Advantage: Legitimizes the difficulties some women face when symptoms are very severe
      • Disadvantage: Pathologizes an experience many consider to be normal

Disruptive Mood Dysregulation Disorder

  • Severe temper outbursts occurring frequently, against a backdrop of angry or irritable mood
    • Diagnosed only in children 6-18
    • Criteria for manic/hypomanic episode are not met
    • Designed in part to combat overdiagnosis of bipolar disorder in youth

DSM-5 Criteria: Major Depressive Disorder (Dysthymia)

A. Depressed mood for most of the day, for more days than not, as indicated by either subjective account or observation by others, for at least 2 years. Note: In children and adolescents, mood can be irritable and duration must be at least 1 year.

B. Presence, while depressed, of two (or more) of the following:

1. Poor appetite or overeating

2. Insomnia or hypersomnia

3. Low energy or fatigue

4. Low self-esteem

5. Poor concentration or difficulty making decisions

6. Feelings of hopelessness

  • DSM-5 Criteria: Major Depressive Disorder (Dysthymia), continued

C. During the 2-year period (1 year for children or adolescents) of the disturbance, the person has never been without the symptoms in criteria A and B for more than 2 months at a time.

D. Criteria for major depressive disorder may be continuously present for 2 years.

E. There has never been a manic episode or a hypomanic episode, and criteria have never been met for cyclothymic disorder.

F. The disturbance is not better explained by a persistent schizoaffective disorder, schizophrenia, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.

G. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hypothyroidism).

H. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify if:

  • Current severity: Mild, moderate, severe; With anxious distress; With mixed features; With melancholic features; With atypical features; With mood-congruent psychotic features; With mood-incongruent psychotic features; With peripartum onset; Early onset: If onset is before age 21 years;
  • DSM-5 Criteria: Major Depressive Disorder (Dysthymia), continued
  • Late onset: If onset is at age 21 years or older; Specify (for most recent 2 years of dysthymic disorder):
  • With pure dysthymic syndrome: if full criteria for a major depressive episode have not been met in at least the preceding 2 years.
  • With persistent major depressive episode: if full criteria for a major depressive episode have been met throughout the preceding 2-year period.
  • With intermittent major depressive episodes, with current episode: if full criteria for a major depressive episode are currently met, but there have been periods of at least 8 weeks in at least the preceding 2 years with symptoms below the threshold for a full major depressive episode.
  • With intermittent major depressive episodes, without current episode: if full criteria for a major depressive episode are not currently met, but there has been one or more major depressive episodes in at least the preceding 2 years.
  • In full remission, in partial remission

From American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC.

Prevalence of Mood Disorders

  • Worldwide lifetime prevalence of MDD: 16%
    • 6% have experienced major depression in last year
  • Sex differences
    • Females are twice as likely to have major depression
    • Bipolar disorders approximately equally affect males and females
    • Women more likely to experience rapid cycling
    • Women more likely to be in depressive period
    • Occurs less often in prepubertal children
    • Rapid rise in adolescents
    • Adults over 65 have about 50% less prevalence than general population
    • Bipolar same in childhood, adolescence and adults
    • Prevalence of depression seems to be similar across subcultures

Life Span Developmental Influences on Mood Disorders

  • Young children typically don’t show classic mania or bipolar symptoms
    • Mood disorder may be misdiagnosed as ADHD
    • Children are being diagnosed with bipolar disorders at increasingly high rates
    • Depression in elderly between 14% and 42%
      • Co-occurrence with anxiety disorders
      • Less gender imbalance after 65 years of age
  • Causes of Mood Disorders: Familial and Genetic Influences
    • Family studies
      • Risk levels are elevated if a relative is diagnosed with a mood disorder
      • Relatives of bipolar disorder are more likely to have unipolar depression
    • Twin studies
      • Concordance rates are high in identical twins
        • Two to three times more likely to present with mood disorders than a fraternal twin of a depressed co-twin
      • Severe mood disorders have a strong genetic contribution
      • Heritability rates are higher for females compared to males
    • Neurobiological Influences
      • Neurotransmitter systems
        • Mood disorders are related to low levels of serotonin
        • Permissive hypothesis: Low serotonin “permits” other neurotransmitters to vary more widely, increasing vulnerability to depression
    • The endocrine system
      • Increased levels of cortisol
      • Stress hormones decrease neurogenesis in the hippocampus which means that is not able to less able to make new neurons
  • Sleep disturbance
    • Sleep is always affected by mood disorders
    • Depressed patients are known to have quicker and more intense REM sleep compared to normal people
    • Sleep deprivation may temporarily improve depressive symptoms in bipolar patients
  • Psychological Dimensions
    • Stress is strongly related to mood disorders as increased stress leads to poorer prognosis and longer remission
    • People who are vulnerable to depression might be more likely to enter situations that will lead to stress
    • Learned Helplessness
    • When an individual feels that he or she doesn’t have control on their lives they might not try and improve their situation leading to mood disorders.
    • Negative cognitive styles are a risk factor for depression
    • Depressive Attributional Style
      • Internal attributions of negative outcomes
        • contribute to a sense of hopelessness
    • Cognitive Theory
      • Negative coping styles
      • Types of cognitive errors
        • Arbitrary inference – overemphasize the negative aspects of a mixed situation
        • Overgeneralization – negatives apply to all situations
      • Cognitive errors and the depressive cognitive triad
        • Think negatively about oneself
        • Think negatively about the world
        • Think negatively about the future
  • Social and Cultural Dimensions
    • Marital dissatisfaction is strongly related to depression
    • Lack of social support is related to depression
    • Substantial social support predicts recovery from depression
  • Gender Differences in Mood Disorders
    • Women account for 7 out of 10 cases of major depressive disorder
    • Women socialized to have stronger perception of uncontrollability
    • Parenting style makes girls less independent
    • Women more sensitive to relationship disruptions (e.g., breakups, tension in friendships)
    • Women ruminate more than men
  • An Integrative Theory
    • Biological and psychological vulnerabilities interact with stressful life events to cause depression
    • Biological vulnerability: e.g., overactive neurobiological response to stress
    • Psychological vulnterability: e.g., depressive cognitive style

Treatment of Mood Disorders: Medication

  • Antidepressants
    • Selective serotonin reuptake inhibitors
    • Tricyclic antidepressants
    • Monoamine oxidase inhibitors
    • Mixed reuptake inhibitors (e.g., serotonin/norepinephrine reuptake inhibitors)
    • Discontinuation is common
    • Also dangerous in combination with cold medicine
    • Lithium 
      • Lithium carbonate = a common salt
      • Treatment of choice for bipolar disorder
      • Considered a mood stabilizer because it treats depressive and manic symptoms
      • Toxic in large amounts
      • Dose must be carefully monitored
      • Effective for 50% of patients
      • Why lithium works remains unclear
    • Electroconvulsive Therapy (ECT)
      • Effective for medication-resistant depression
      • The nature of ECT
        • A small amount of electrical current applied to the brain which results in temporary seizures.
        • Improves moods
        • Side effects:
          • Short-term memory loss which is usually restored
          • Some patients suffer long-term memory loss
          • Mechanism is unclear
    • Transcranial Magnetic Stimulation
      • Uses magnets to generate a precise localized electromagnetic pulse
      • Lesser side effects but leads to headaches
      • However, this is no better than ECT
  • Psychosocial Treatments
    • Cognitive-behavioral therapy
      • Addresses cognitive errors in thinking and core values
      • Also includes behavioral changing activities (scheduling valued activities)
    • Interpersonal psychotherapy
      • Looks at improving problematic relationships
    • Prevention
      • Preemptive psychosocial care for people at risk


  • Underreported; actual rate may be 2-3x higher
  • Particularly prevalent in young adults
  • Gender differences
    • Males complete more suicides than females
    • Females attempt suicide more often than males
    • Disparity is due to males using more lethal methods
    • Exception: Suicide more common among women in China
      • May reflect cultural acceptability; suicide is seen as an honorable solution to problems
  • Risk factors
    • Alcohol use and abuse
    • Stressful life event, especially humiliation
    • Low serotonin levels
    • Plan and access to lethal methods
    • Preexisting psychological disorder
    • Past suicidal behavior
    • Suicide in the family
  • Vulnerability for Suicidal Behavior
  • Suicide Contagion – A person is more likely to commit suicide after hearing about someone else committing suicide
  • Media accounts may worsen the problem because thyee sensationalize or romanticize the idea of suicide as well as elaborately describe lethal methods of committing suicide
  • Suicide Prevention can be done by identifying a potential risk patient and conduction a risk assessment (ideation, plans, intent, means, etc.).
    • Clinician and patient develop safety plan (e.g., who to call, strategies for coping with suicidal thoughts)
    • In some cases, sign no-suicide contract
    • CBT can reduce suicide risk
    • Removal of access to lethal or dangerous equipment
      • If you think someone is at risk, talk to them and ensure they’re getting needed support

Neurodevelopmental disorders

  • Are a group of conditions characterized by an early onset and persistent course that are believed to be the result of disruptions to normal brain development.
  • It is seen early in development, often before the child enters school, and are characterized by developmental deficits that produce impairments of personal, social, academic, or occupational functioning.

Intellectual disability

  • Intellectual disability (intellectual developmental disorder) is a disorder with onset during the developmental period that includes both intellectual and adaptive functioning deficits in conceptual, social, and practical domains.


A. Deficits in intellectual functions, such as reasoning, problem solving, planning, abstract thinking, judgment, academic learning, and learning from experience, confirmed by both clinical assessment and individualized, standardized intelligence testing.

B. Deficits in adaptive functioning that result in failure to meet developmental and sociocultural standards for personal independence and social responsibility.

Without ongoing support, the adaptive deficits limit functioning in one or more activities of daily life, such as communication, social participation, and independent living, across multiple environments, such as home, school, work, and community.

C. Onset of intellectual and adaptive deficits during the developmental period.

  • Adaptive functioning
  • Adaptive functioning involves adaptive reasoning in three domains: conceptual, social, and practical.
  • The conceptual (academic) domain involves competence in memory, language, reading, writing, math reasoning, acquisition of practical knowledge, problem solving, and judgment in novel situations, among others.
  • The social domain involves awareness of others’ thoughts, feelings, and experiences; empathy; interpersonal communication skills; friendship abilities; and social judgment, among others.
  • The practical domain involves learning and self-management across life settings, including personal care, job responsibilities, money management, recreation, self-management of behavior, and school and work task organization, among others.
  • Retardation severity & IQ ranges
Diagnosed level of MR Corresponding IQ range
Mild retardation 50-55 to approx. 70
Moderate retardation 35-40 to 50-55
Severe retardation 20-25 to 35-40
Profound retardation Below 20-25

Mild intellectual disability

  • The largest number of individuals are diagnosed with Mild ID
  • People in this group are considered educable.
  • Usually no signs of brain pathology or other physical anomalies.
  • Supervision is required by not all the time. This is because of a limited ability to foresee the consequences of their actions.
  • Their intellectual levels are comparable to those of average 8-11 year old children.
  • They can socially adjust as much as adolescents but they lack quick problem solving, imagination, inventiveness & judgment.

Moderate intellectual disability

  • Referred to as trainable because they can master certain routine skills such as cooking with specialized instructions.
  • Their intellectual levels are similar to those of average 4-7 year old children.
  • Some can be taught to read & write a little and manage to achieve a fair command of spoken language.
  • Their rate of learning is low and understanding is limited.

Severe intellectual disability

  • They are known as dependent retarded.
  • Limited levels of personal hygiene & self-help skills.
  • Motor & speech development are severely retarded with sensory defects & motor handicaps.
  • They are always dependent on others for care.
  • Some individuals benefit greatly, from training and perform simple occupational tasks under supervision.

Profound intellectual disability

  • They are called as ‘life support retarded’.
  • Severe deficiency in adaptive behavior & inability to master even the simplest tasks.
  • Speech production is underdeveloped.
  • Severe physical deformities with limited growth
  • Convulsive seizures, mutism, deafness and other physical anomalies are common.
  • They remain in custodial care all their lives.
  • They have poor health & low resistance to diseases & thus have a short life expectancy.
  • Severe & profound retardation can be diagnosed in infancy because of the presence of obvious physical malformations, grossly delayed development.
  • They show a marked impairment of overall intellectual functioning.

Causal factors

        Genetic-Chromosomal factors

  • ID especially mild tends to run in families.
  • Poverty, nutrition and sociocultural deprivation are associated with ID
  • Genetic & chromosomal factors play a role in the etiology of Down Syndrome, Fragile X.

        Infections & toxic agents

  • ID can develop due to infections such as HIV (during mother’s pregnancy), viral encephalitis, and genital herpes.
  • Toxic agent such as carbon monoxide, alcohol, drugs, and lead may cause brain damage during fetal development or post birth.
  • Brain damage results from incompatibility in blood types between mother & fetus.

 Trauma (physical injury)

  • Physical injury at birth can result in retardation.
  • Malposition of the fetus or other complications during labour may irreparably damage the infant’s brain.
  • Bleeding within the brain is the result of such birth trauma.
  • Lack of sufficient oxygen to the brain, also know as hypoxia, stemming from delayed breathing or other causes may damage the brain.

       Ionizing Radiation

  • Radiation may act directly on the fertilized ovum or may produce gene mutations in the sex cells of either or both parents which may lead to defective offspring.

       Malnutrition & other biological factors

  • Malnutrition may affect mental development by altering a child’s responsiveness, curiosity & motivation to learn which lead to relative retardation of intellectual facility.
  • Organic intellectual disability syndromes


  • First described by Langdon Down.
  • It occurs due to the the trisomy of chromosome 21,
    • The individual has 47 rather than the normal 46 chromosomes.
  • It is linked with moderate & mild mental retardation.

The clinical picture

Physical Characteristics

  • The tongue which seems too large for the mouth show deep fissures.
  • The iris of the eye is speckled.
  • The eyes appear almond shaped and the skin of the eyelid tends to be thick.
  • The neck & the hands are short & broad.
  • The fingers are stubby & the little finger is curved than the other fingers.
  • The face & nose are flat & broad as is the back of the head.
  • Children with down syndrome are able to learn self-help skills, acceptable social behavior & routine manual skills that enable them to be of assistance in a family or institutional setting.
  • Their greatest deficits are in verbal & language related skills.
  • Advancing age in either parent increases the risk of the trisomy 21 anomaly, although the effect of maternal age is greater.

Phenylketonuria (PKU)

  • Cannot break down phenylalanine, which is found in some foods
  • Results in ID when the individual eats phenylalanine
  • Now, test at birth can detect PKU > diets without phenylalanine actually prevent development of intellectual disability and other problems
  • It becomes apparent between 6 & 12 months after birth.
  • Vomiting, a peculiar odor, infantile eczema & seizures may occur during the early weeks of life.
  • The first symptoms noticed are signs of ID which may be moderate to severe.
    • Lack of motor coordination & other neurological problems caused by the brain damage are common.
    • The eyes, skin & hair of the untreated PKU patients are pale.
  • With early detection & treatment, the deterioration process can be arrested.
    • For a baby to inherit PKU both parents must carry a recessive gene.
  • PKU patients are advised to follow a restricted diet over their life span in order to prevent cognitive impairment.

Cranial Anomalies

  • ID is associated with a number of conditions that involve changes in head size & shape.

     Macrocephaly (Large headedness)

  • This is a case where there is a noticeable increase in the size and weight of the brain, as well as an enlargement of the skull
    • Leads to visual impairment, convulsions, and other neurological symptoms.
    • It results from the abnormal growth of glial cells that are meant to support structure of the brain tissue.

    Microcephaly (Small- headedness)

  • The circumference of the head rarely exceeds 17 inches, compared with the normal size of 22 inches.
  • Associated with a type of ID resulting from impaired development of the brain
  • They are invariably short in stature, but having relatively normal musculature & sex organs.
  • The skull is cone shaped with a receding skin & forehead.
  • They fall within moderate, severe, & profound categories of ID.
  • Preventive measures focus on the avoidance of infection & radiation during pregnancy.


  • This occurs due to the accumulation of an abnormal amount of cerebrospinal fluid within the cranium
    • The CSF then causes damage to the brain tissue and enlarges the skull.
  • Prebirth, the head either is enlarged at birth or begins to enlarge soon thereafter as a result of a disturbance in the formation, absorption & circulation of CSF.
  • It can also arise in infancy or early childhood following the development of a brain tumor, subdural hematoma, meningitis or other conditions.
  • The brain damage leads to intellectual impairment & such effects as convulsions or loss of sight & hearing.
  • The retardation vary from severe to profound.
  • Shunting devices are inserted to drain CSF for the treatment.

Autism spectrum disorders


A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history

1. Deficits in social-emotional reciprocity, ranging for example from abnormal social approach and failure of normal back-and-forth conversation to reduced sharing of interests, emotions, or affect to failure to initiate or respond to social interactions.

2. Deficits in nonverbal communicative behaviors used for social interaction ranging for example from poorly integrated verbal and nonverbal communication to abnormalities in eye contact and body language or deficits in understanding and use of gestures to a total lack of facial expressions and nonverbal communication.

3. Deficits in developing, maintaining, and understanding relationships ranging for example from difficulties adjusting behavior to suit various social contexts to difficulties in sharing imaginative play or in making friends to absence of interest in peers.

Three levels of severity

  • Level 1— “Requiring support”
    • Level 2— “Requiring substantial support”
    • Level 3— “Requiring very substantial support”
    • Described qualitatively and, as yet, has no quantitative equivalent

The clinical picture

  • Main characteristic: Failure to develop age-appropriate social relationships
    • Trouble initiating and maintaining relationships
    • Autistic children do not show any need for affection or contact with anyone and they do not seem to know or care who their parents are.
    • The inability to respond to others is due to a lack of social understanding-a deficit in the ability to attend to social cues from others.
  • Mind Blindness: inability to take the attitude of others or to see things as others do.
  • Deficits in joint attention – the ability to communicate interest in an external stimulus and another person at the same time
    • Trouble with nonverbal communication
      • May lack appropriate expressions, tone
      • Imitative deficit where they do not effectively learn by imitation and  have limited use of speech
      • Persistent echolalia-the parrot like repetition of a few words is found in autistic children.
    • Self stimulation – repetitive movements as head banging, spinning & rocking which may continue by the hour.
  • They show an active aversion to auditory stimuli, crying even at the sound of a parent’s voice.

  Intellectual ability

  • Some autistic children show marked impairment in cognitive or intellectual tasks such as memory tasks but not all
  • Some may be have normal IQ
  • Preference for the status quo – maintenance of sameness
  • Severe forms: Stereotyped or ritualistic behavior

Causal factors

  • Disturbance of the CNS is involved. However it is unclear what.
  • Family and heredity: There is a 3-5% risk of a sibling being autistic in families with one autistic child.
  • Family & twin studies shows that autism is inherited.
  • Studies pointed to the existence of a possible genetic defect, fragile X, a constriction or breaking off of the end portion of the X sex chromosome that appears to be determined by a specific gene defect.


  • Psychosocial  treatments
    • Behavioral approaches
      • Skill building
      • Reduce problem behaviors
      • Communication and language training
      • Increase socialization
      • Naturalistic teaching strategies
    • Early intervention is critical – may “normalize” the functioning of the developing brain
  • Biological treatments
    • Medical intervention has had little positive impact on core dysfunction
  • Indicators of good prognosis
    • High IQ, good language ability
  • Integrated treatments
    • Preferred model: Multidimensional, comprehensive focus
      • Children offered special education at school focusing on communication
      • Judicious use of medication in some cases
      • Families given support too

Specific learning disorder

  • It refers to retardation, disorder or delayed development, may be manifested in language, speech, mathematical, or motor skills, & it is not due to any reliably demonstrable physical or neurological defect.
  • The origin includes an interaction of genetic, and environmental factors, which affect the brain’s ability to perceive or process verbal or nonverbal information efficiently and accurately.
  • Specific Learning disorder types:
  • Dyslexia (formerly called reading disorder) involves significant difficulty with word recognition, reading comprehension, and typically written spelling as well.
  • They may be markedly deficient in spelling.
  • Dyslexic people routinely omit, add, distort written words, and their reading is typically painfully slow & halting.
  • Dyscalculia (formerly called mathematics disorder) involves difficulty in producing or understanding numbers, quantities, or basic arithmetic operations.
    • Dyscalculia – involves difficulty in making patterns, understanding them, and drawing
  • SLD is identified when there is disparity between the child’s expected academic level& their actual performance in one or more school subjects such as math, spelling, writing, or reading.

Specific learning disorder – Criteria

  • A. Difficulties learning and using academic skills, as indicated by the presence of at least one of the following symptoms that have persisted for at least 6 months, despite the provision of interventions that target those difficulties:
  • 1. Inaccurate or slow and effortful word reading (e.g., reads single words aloud incorrectly or slowly and hesitantly, frequently guesses words, has difficulty sounding out words).
  • 2. Difficulty understanding the meaning of what is read (e.g., may read text accurately but not understand the sequence, relationships, inferences, or deeper meanings of what is read).
  • 3. Difficulties with spelling (e.g., may add, omit, or substitute vowels or consonants).
  • 4. Difficulties with written expression (e.g., makes multiple grammatical or punctuation errors within sentences; employs poor paragraph organization; written expression of ideas lacks clarity).
  • 5. Difficulties mastering number sense, number facts, or calculation (e.g., has poor understanding of numbers, their magnitude, and relationships; counts on fingers to add single-digit numbers instead of recalling the math fact as peers do; gets lost in the midst of arithmetic computation and may switch procedures).
  • 6. Difficulties with mathematical reasoning (e.g., has severe difficulty applying mathematical concepts, facts, or procedures to solve quantitative problems).
  • B. The affected academic skills are substantially and quantifiably below those expected for the individual’s chronological age, and cause significant interference with academic or occupational performance, or with activities of daily living, as confirmed by individually administered standardized achievement measures and comprehensive clinical assessment. For individuals age 17 years and older, a documented history of impairing learning difficulties may be substituted for the standardized assessment.
  • C. The learning difficulties begin during school-age years but may not become fully manifest until the demands for those affected academic skills exceed the individual’s limited capacities (e.g., as in timed tests, reading or writing lengthy complex reports for a tight deadline, excessively heavy academic loads).
  • D. The learning difficulties are not better accounted for by intellectual disabilities, uncorrected visual or auditory acuity, other mental or neurological disorders, psychosocial adversity, lack of proficiency in the language of academic instruction, or inadequate educational instruction.

Causal factors

  • Learning disabilities are the products of subtle CNS impairments.
  • The left brain has been hypothesized to be the anatomical site of this dysfunction
  • It results from some sort of immaturity, deficiency or dysregulation limited to those brain functions which mediate the cognitive skills (usually frontal lobe areas)
  • Dyslexia is associated with a failure of the brain to develop in a normally asymmetrical manner with respect to the right & left hemispheres.
  • Causes of deficits in mathematics are believed to be multifactorial, including genetic, maturational, cognitive, emotional, educational, and socioeconomic factors. Prematurity and very low birth weight are also a risk factor for specific learning disorder, including mathematicsFrom studies found that LD is genetically transmitted.


  • Parent counseling, 
  • daily practice direct practice in spelling and sentence writing as well as a review of grammatical rules.
  • Intensive and continuous administration of individually tailored, one-on-one expressive and creative writing therapy appears to effect favorable outcome.
  • Flash cards, workbooks, and computer games can be a viable part of this treatment
  • Effective remediation programs begin by teaching the child to make accurate associations between letters and sounds.
    • After individual letter-sound associations have been mastered, remediation can target larger components of reading such as syllables and words.
    • The exact focus of any reading program can be determined only after accurate assessment of a child’s specific deficits and weaknesses.

Attention Deficit/Hyperactivity Disorder

ADHD is a neuropsychiatric condition which affects preschoolers, children, adolescents and adults. It is characterized by a pattern of diminished sustained attention and increased impulsivity or hyperactivity.

Clinical Features

Infants with ADHD are active in the crib, sleep little, and cry a great deal.

School children may attack a test rapidly, but may answer only the first two questions. They may be unable to wait to be called on in school and may respond before everyone else. At home, they cannot be put off for even a minute. Impulsiveness and an inability to delay gratification are characteristic. Children with ADHD are often susceptible to accidents.


  • Hyperactivity
  • Attention deficit (short attention span, distractibility, perseveration, failure to finish tasks, inattention, poor concentration)
  • Impulsivity (action before thought, abrupt shifts in activity, lack of organization, jumping up in class)
  • Memory and thinking deficits
  • SLD
  • Speech and hearing deficits
  • Perceptual motor impairment
  • Emotional lability
  • Developmental coordination disorder
  • Behavioural symptoms of aggression and defiance
  • School difficulties
  • Co-morbid communication disorders



  • Genetic factors
    • Increased concordance in monozygotic compared to dizygotic twins, as well as a marked increased risk of 2 to 8 times for siblings as well as parents of an ADHD child, compared to the general population.
    • Association of the dopamine transporter gene (DAT1) with ADHD.
    • association between the dopamine 4 receptor seven-repeat
    • Allele gene (DRD4) gene and ADHD.
  1. Neurophysiologic Factors
  2. EEG studies- increased beta (combined type of ADHD) and theta activity
  • Neuroanatomical Aspects
  • neuroanatomical correlations for the superior and temporal cortices with focusing attention; external parietal and corpus striatal regions with motor executive functions; the hippocampus with encoding of memory traces; and the prefrontal cortex with shifting from one stimulus to another.
  • Brainstem, which contains the reticular thalamic nuclei function, is involved in sustained attention.
  • Populations of children with ADHD show evidence of both decreased volume and decreased activity in prefrontal regions, anterior cingulated, globus pallidus, caudate, thalamus, and cerebellum.
  • PET scans have also shown that female adolescents with ADHD have globally lower glucose metabolism than both control female and male adolescents without ADHD. One theory postulates that the frontal lobes in children with ADHD do not adequately inhibit lower brain structures, an effect leading to disinhibition.
  • Neurochemical Factors
  • Dopamine is a major focus of clinical investigation.
  • Prefrontal cortex has been implicated based on its role in attention and regulation of impulse control.
  • Stimulants, known to be the most effective medications in the treatment of ADHD, affect both dopamine and norepinephrine, leading to neurotransmitter hypotheses that may include dysfunction in both the adrenergic and dopaminergic systems. Stimulants increase catecholamine concentrations by promoting their release and blocking their uptake.
  • Developmental Factors
  • Perinatal insult to the brain during early infancy caused by infection, inflammation, and trauma may, in some cases, be contributing factors in the emergence of ADHD symptoms. September is a peak month for births of children with ADHD with and without comorbid learning disorders. The implication is that prenatal exposure to winter infections during the first trimester may contribute to the emergence of ADHD symptoms in some susceptible children.
  • Psychosocial Factors
  • Severe chronic abuse, maltreatment, and neglect are associated with certain behavioral symptoms that overlap with ADHD including poor attention and poor impulse control. Predisposing factors may include the child’s temperament and genetic–familial factors.

Eating and Sleep-Wake Disorders

Eating Disorders

  • Major types of DSM-5 eating disorders
    • Anorexia nervosa and bulimia nervosa
      • Severe disruptions in eating behavior
      • Weight and shape have disproportionate influence on self-concept
      • Extreme fear and apprehension about gaining weight
      • Strong sociocultural origins – driven by Western emphasis on thinness
  • Additional DSM-5 eating disorder:
  •  Binge eating disorder
    • Involves disordered eating behavior (binges)
    • May involve fewer cognitive distortions about weight and shape
  • Obesity – considered a symptom of some eating disorders but not a disorder in and of itself
    • Alarming increase in rates
    • Presents serious health risks (e.g., cardiovascular strain, increased risk of early death)
    • Determined by BMI
  • Bulimia Nervosa: Overview and Defining Features
    • Hallmark of bulimia nervosa and binge eating disorder is binge eating
      • Eating excess amounts of food in a distinct period of time
      • Eating is seemingly uncontrollable
      • Associated with guilt, shame or regret
      • May hide behavior from family members
      • Foods consumed are often high in sugar, fat or carbohydrates
    • Compensatory behaviors – designed to “make up for” binge eating
      • Most common: Purging  (Vomiting)
        • Most common purging method: Self-induced vomiting
        • May also include use of diuretics or laxatives
      • Excessive exercise
      • Fasting or food restriction
        • Most are within 10% of normal body weight
        • Purging methods can result in severe medical problems
          • Erosion of dental enamel, electrolyte imbalance
          • Kidney failure, cardiac arrhythmia, seizures, intestinal problems, permanent colon damage
    • Associated psychological features
      • Most are overly concerned with body shape
      • Fear of gaining weight
      • Most have comorbid psychological disorders
        • 20% meet criteria for a mood disorder
        • 50-70% have met criteria for a mood disorder at some point
        • 80% have met criteria for an anxiety disorder at some point
        • Nearly 2 in 5 abuse substances

Anorexia Nervosa: Overview and Defining Features

  • Extreme weight loss – hallmark of anorexia
    • Restriction of calorie intake below energy requirements (Sometimes defined as 15% below expected weight)
    • Intense fear of weight gain
    • Often begins with dieting
    • Subtypes:
      • Restricting: Diet to limit calorie intake
      • Binge-eating-purging: Purge to limit calorie intake
  • Most show marked disturbance in body image
  • Most have comorbid psychological disorders
    • 70% are depressed at some point
    • Higher than average rates of substance abuse and OCD
  • Starving body borrows energy from internal organs, leading to organ damage including cardiac damage > can cause heart attack
  • Medical consequences
    • Amenorrhea (loss of periods in women)
    • Dry skin
    • Brittle hair and nails
    • Sensitivity to cold temps
    • Lanugo
    • Cardiovascular problems
    • Electrolyte imbalance
  • Most deadly mental disorder due to organ damage

Binge Eating Disorder:  Overview and Defining Features

  • New disorder in DSM-5
  • Binge eating without associated compensatory behaviors
  • Associated with distress and/or functional impairment (e.g., health risk, feelings of guilt)
  • Excessive concern with weight or shape may or may not be present
  • Associated Features
    • Approximately 20% of individuals in weight-control programs suffer from BED
    • Approximately half of candidates for bariatric surgery suffer from BED
    • Better response to treatment than other eating disorders
    • Tend to be older than sufferers of anorexia and bulimia
    • Higher rates of psychopathology than non-bingeing obese individuals
  • Causes of Eating Disorders
    • Media and cultural considerations
      • Media portrayals: thinness linked to success, happiness
      • Cultural emphasis on dieting
      • Standards of ideal body size
        • Frequently changing and difficult to achieve
    • Social Factors
      • Dieting and dietary restraint
        • Adolescent dieting leads to an 8x greater risk of developing an eating disorder
        • Adolescents tend to internalize the standards of friendship groups (e.g., a teenager is more likely to diet if her friends also diet)
        • May paradoxically cause weight gain
          • Produces stress and withdrawal symptoms that increase cravings for food
      • During periods of restricted food intake, people become preoccupied with food and eating
        • Classic study conducted during WWII: Volunteers placed on strict diets started thinking, writing and reading more about food
    • Family Influences
      • Parents with distorted perception of food and eating may restrict children’s intake too (e.g., put chubby toddlers on unnecessary diets)
      • Families of individuals with anorexia are often:
        • High achieving
        • Concerned with external appearances
        • Overly motivated to maintain harmony > leads to poor communication and denial of problems
      • Disordered eating also strains family relationships
        • Causes parental guilt and frustration
    • Biological Factors
      • Some genetic component
        • Relatives of people with eating disorders are 4-5x more likely to develop an eating disorder
      • Not clear what is inherited
        • May be nonspecific traits like emotional instability or impulsivity
      • Low levels of serotonergic activity often found in eating disorders
        • Not clear whether this is a cause or consequence, but likely to contribute to maintenance of eating disorders
  • Psychological Dimensions
    • Low sense of personal control and self-confidence
    • Perfectionistic attitudes
    • Distorted body image
    • Preoccupation with food
    • Mood intolerance


  • Cognitive-behavioral therapy (CBT)
    • Basic components of CBT: Identifying maladaptive thinking patterns and behavioral habits, then gradual practice of new habits
  • Interpersonal psychotherapy
    • Equally as effective as CBT
  • Self-help techniques
    • Also appear effective
  • General goals and strategies
    • Weight restoration for Anorexia
    • Psychoeducation
    • Behavioral and cognitive interventions
      • Target food, weight, body image, thought and emotion
    • Treatment often involves the family
    • Long-term prognosis for anorexia is poorer than for bulimia
  • Medical and drug treatments
    • Antidepressants
      • Can help reduce binging and purging behavior
      • Usually not efficacious in the long-term
  • Preventing Eating Disorders
    • Often focuses on promoting body acceptance in adolescent girls
    • Identify specific targets
      • Early weight concerns
    • Screening for at-risk groups
    • Provide education
      • Normal weight limits
      • Effects of calorie restriction

Sleep-Wake Disorders

  • Just a few hours’ sleep deprivation decreases immune functioning and has an effect on energy, mood, memory, concentration, attention
  • Sleep loss may bring on feelings of depression in non-depressed individuals
    • However, sleep deprivation may have an antidepressant effects in depressed individuals
  • Sleep can be understood in the follow Polysomnographic (PSG) evaluation:
    • Electroencephalograph (EEG) – brain waves
    • Electrooculograph (EOG) – eye movements
    • Electromyography (EMG) – muscle movements
    • Detailed history, assessment of sleep hygiene and sleep efficiency
  • Actigraph
    • Portable wearable device sensitive to movement – can detect different stages of wakefulness/sleep
  • Two major types of sleep disorders
    • Dyssomnias
      • Difficulties in amount, quality, or timing of sleep
    • Parasomnias
      • Abnormal behavioral and physiological events during sleep

Sleep–Wake Disorders: The Major Dyssomnias

  • The Dyssomnias: Overview and Defining Features of Insomnia
  • Insomnia disorder
    • One of the most common sleep disorders
    • The individual engages in Microsleeps
    • Problems initiating/maintaining sleep (e.g., trouble falling asleep, waking during night, waking too early in the morning)
    • Insomnia can be categorized in terms of how it affects sleep (e.g., sleep onset insomnia, sleep-maintenance insomnia, or early-morning awakening).
    • Insomnia can also be classified according to its duration (e.g., transient, short term, and long term).
    • Many adults report daytime sleepiness
    • Only diagnosed as a sleep disorder if it is not better explained by a different condition (e.g., generalized anxiety disorder
    • Often associated with medical and/or psychological conditions
      • Anxiety, depression, substance use
    • Affects females twice as often as males
    • Associated features
      • Unrealistic expectations about sleep
      • Believe lack of sleep will be more disruptive than it usually is


  • A. A predominant complaint of dissatisfaction with sleep quantity or quality, associated with one (or more) of the following symptoms:
  • 1. Difficulty initiating sleep. (In children, this may manifest as difficulty initiating sleep without caregiver intervention.)
  • 2. Difficulty maintaining sleep, characterized by frequent awakenings or problems returning to sleep after awakenings. (In children, this may manifest as difficulty returning to sleep without caregiver intervention.)
  • 3. Early-morning awakening with inability to return to sleep.
  • B. The sleep disturbance causes clinically significant distress or impairment in social, occupational, educational, academic, behavioral, or other important areas of functioning.
  • C. The sleep difficulty occurs at least 3 nights per week.
  • D. The sleep difficulty is present for at least 3 months.
  • E. The sleep difficulty occurs despite adequate opportunity for sleep.
  • F. The insomnia is not better explained by and does not occur exclusively during the course of another sleep-wake disorder (e.g., narcolepsy, a breathing-related sleep disorder, a circadian rhythm sleep-wake disorder, a parasomnia).
  • G. The insomnia is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication).
  • H. Coexisting mental disorders and medical conditions do not adequately explain the predominant complaint of insomnia.

Types of Insomnia

Persistent Insomnia

  • Persistent insomnia is a group of conditions in which the problem is difficulty falling asleep or remaining asleep.
  • Patients may not experience anxiety but release the anxiety through physiological channels;
  • Individuals suffering complain of apprehensive feelings or ruminative thoughts that appear to keep them from falling asleep

Psychophysiological Insomnia

  • A primary complaint of difficulty in going to sleep.
  • Objects associated with sleep (e.g., the bed, the bedroom) likewise become conditioned stimuli that evoke insomnia.
  • Thus, psychophysiological insomnia is sometimes called conditioned insomnia

Idiopathic Insomnia

  • Idiopathic insomnia starts early in life, sometimes at birth, and continues throughout life.
  • Suspected causes include neurochemical imbalance in brainstem reticular formation, impaired regulation of brainstem sleep generators (e.g., raphe nuclei, locus ceruleus), or basal forebrain dysfunction.

Primary Insomnia

  • Primary insomnia is diagnosed when the chief complaint is nonrestorative sleep or difficulty in initiating or maintaining sleep, and the complaint continues for at least a month.
  • It is characterized both by difficulty falling asleep and by repeated awakening.
  • Increased night time physiological or psychological arousal and negative conditioning for sleep are frequently evident.
  • Patients with primary insomnia are generally preoccupied with getting enough sleep.
  • The more they try to sleep, the greater the sense of frustration and distress and the more elusive sleep becomes.

Subjective Insomnia            

  • Sleep state misperception (also known as subjective insomnia) is characterized by a dissociation between the patient’s experience of sleeping and the objective polygraphic measures of sleep.
  • It is diagnosed when a patient complains of difficulty initiating or maintaining sleep and no objective evidence of sleep disruption is found.
  • Sleep state misperception can occur in individuals who are apparently free from psychopathology or it can represent a somatic delusion or hypochondriasis

Causes of Insomnia Disorder

  • Pain and physical discomfort are a major reason for insomnia
  • Delayed temperature rhythm (body temperature doesn’t drop until later, leading to delayed drowsiness)
  • Light, noise, temperature influence ability to sleep
  • Other sleep disorders cause secondary insomnia
    • Apnea
    • Periodic limb movement disorder
  • Stress and anxiety
  • Parental effects on children’s sleep
    • Parents’ negative beliefs about sleep linked to more infant waking during the night
    • Some kids learn to fall asleep only with a parent present
  • Culture and Sleep: Differences in Children’s Sleep


  • CBT: combination of behavioral and cognitive techniques to overcome dysfunctional sleep behaviors, misperceptions, and distorted, disruptive thoughts about sleep.
  • Behavioral techniques include universal sleep hygiene, stimulus control therapy, sleep restriction therapy, relaxation therapies, and biofeedback.
  • Stimulus Control Therapy: The goal is to break the cycle of problems commonly associated with difficulty initiating sleep by attempting to undo conditioning that undermines sleep, it helps reduce both primary and reactive factors involved in insomnia.
  • Sleep restriction therapy: Restricting time in bed can help consolidate sleep for patients who find themselves lying awake in bed unable to sleep
    • If the patient reports sleeping only 5 hours of a scheduled 8 hours in bed, reduce the time in bed.

Hypersomnolence Disorder

  • Sleeping too much or excessive sleep
    • May manifest as long nights of sleep or frequent napping
  • Experience excessive sleepiness as a problem
  • Causes are not well understood due to limited research
  • Often associated with other medical and/or psychological conditions
  • Only diagnosed if other conditions don’t adequately explain hypersomnia, which should be the primary complaint
  • Associated features
    • Complain of sleepiness throughout the day
    • Able to sleep through the night


  • A. Self-reported excessive sleepiness (hypersomnolence) despite a main sleep period lasting at least 7 hours, with at least one of the following symptoms:
  • 1. Recurrent periods of sleep or lapses into sleep within the same day.
  • 2. A prolonged main sleep episode of more than 9 hours per day that is nonrestorative (i.e., unrefreshing).
  • 3. Difficulty being fully awake after abrupt awakening.
  • B. The hypersomnolence occurs at least three times per week, for at least 3 months.
  • C. The hypersomnolence is accompanied by significant distress or impairment in cognitive, social, occupational, or other important areas of functioning.
  • D. The hypersomnolence is not better explained by and does not occur exclusively during the course of another sleep disorder (e.g., narcolepsy, breathing-related sleep disorder, circadian rhythm sleep-wake disorder, or a parasomnia).
  • E. The hypersomnolence is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication).
  • F. Coexisting mental and medical disorders do not adequately explain the predominant complaint of hypersomnolence.
  • Narcolepsy
    • Principal symptom: Recurrent intense need for sleep, lapses into sleep or napping
      • The presence of at least one of the following:
      • 1. Episodes of cataplexy, defined as either (a) or (b), occurring at least a few times per month:
      • a. In individuals with long-standing disease, brief (seconds to minutes) episodes of sudden bilateral loss of muscle tone with maintained consciousness that are precipitated by laughter or joking.
      • Hypocretin deficiency, as measured using cerebrospinal fluid (CSF) hypocretin-1 immunoreactivity values
        • Low CSF levels of hypocretin-1 must not be observed in the context of acute brain injury, inflammation, or infection.
      • Going into REM sleep abnormally fast (<15 min), as evidenced by polysomnographic measures
      • These sleep attacks (patients cannot avoid falling asleep) typically occur two to six times a day and last 10 to 20 minutes. They may occur at inappropriate times,
      • Patients with narcolepsy frequently have sleep-onset REM sleep both at night and during daytime naps.
      • Cataplexy ranges from transient weakness in the knees to total loss of skeletal tone during full consciousness.
      • It is triggered by emotion (e.g., anger, laughter) &usually lasts for several seconds to several minutes.
      • The patient may fall to the floor& be unable to speak
  • Facts and statistics – rare condition
    • Affects about .03% to .16% of the population
    • Equally distributed between males and females
    • Onset during adolescence
    • Typically improves over time
  • Include 3 different disorders previously classified as parts of the same disorder:

Obstructive sleep apnea hypopnea where airflow stops, but respiratory system works

  • A. Either (1) or (2):
  • 1. Evidence by polysomnography of at least five obstructive apneas or hypopneas per hour of sleep and either of the following sleep symptoms:
  • a. Nocturnal breathing disturbances: snoring, snorting/gasping, or breathing pauses during sleep.
  • b. Daytime sleepiness, fatigue, or unrefreshing sleep despite sufficient opportunities to sleep that is not better explained by another mental disorder (including a sleep disorder) and is not attributable to another medical condition.

Central sleep apnea (CSA) where respiratory systems stops for brief periods

  • Evidence by polysomnography of five or more central apneas per hour of sleep.
  • B. The disorder is not better explained by another current sleep disorder.
  • Central sleep apnea (CSA), which tends to occur in the elderly, results from periodic failure of CNS mechanisms that stimulate breathing.
  • CSA is the absence of breathing due to lack of respiratory effort.

Sleep-related hypoventilation: Decreased breathing during sleep not better explained by another sleep disorder

  • Polysomnograpy demonstrates episodes of decreased respiration associated with elevated CO2 levels.
  • B. The disturbance is not better explained by another current sleep disorder.

Circadian Rhythm Sleep-Wake Disorders

  • Disturbed sleep (e.g., either insomnia or excessive sleepiness) leading to distress and/or functional impairment (e.g. significantly decreased productivity at work)
  • Specifically due to brain’s inability to synchronize day and night
  • Affects suprachiasmatic nucleus, which stimulates melatonin and regulates sense of night and day


  • A persistent or recurrent pattern of sleep disruption that is primarily due to an alteration of the circadian system or to a misalignment between the endogenous circadian rhythm and the sleep-wake schedule required by an individual’s physical environment or social or professional schedule.
  • B. The sleep disruption leads to excessive sleepiness or insomnia, or both.
  • C. The sleep disturbance causes clinically significant distress or impairment in social, occupational, and other important areas of functioning.Examples
    • Shift work type – job leads to irregular hours
    • Familial type – associated with family history of dysregulated rhythms
    • Delayed or advanced sleep phase type – person’s biological clock is naturally “set” earlier or later than a normal bedtime
    • Circadian Rhythm and Biological Clock
  • Treatments for Sleep Disorders
    • Hypersomnia and narcolepsy
      • Stimulants (i.e., Ritalin)
      • Cataplexy usually treated with antidepressants
    • Breathing-related sleep disorders
      • May include medications, weight loss, or mechanical devices
    • Circadian rhythm sleep-wake disorders
      • Phase delays
        • Moving bedtime later (best approach)
      • Phase advances
        • Moving bedtime earlier (more difficult)
      • Use of very bright light
        • Trick the brain’s biological clock
  • Best approach: Practice healthy “sleep hygiene” (behaviors that lead to adequate quality and quantity of sleep)
    • Also helpful to educate parents about good sleep habits for children
    • Good Sleep Hygiene

The Parasomnias: Nature and General Overview

  • Parasomniasare disorders characterized by abnormal behavioral, experiential, or physiological events occurring in association with sleep, specific sleep stages, or sleep-wake transitionsTwo classes of parasomnias
    • Those that occur during REM (i.e., dream) sleep
    • Those that occur during non-REM (i.e., non-dream) sleep

The Parasomnias: Non-REM Sleep Arousal Disorders


  • Recurrent episodes of incomplete awakening from sleep, usually occurring during the first third of the major sleep episode, accompanied by either one of the following:
  • 1. Sleepwalking: Repeated episodes of rising from bed during sleep and walking about.
  • While sleepwalking, the individual has a blank, staring face; is relatively unresponsive to the efforts of others to communicate with him or her; and can be awakened only with great difficulty.
  • Sleep terrors: Recurrent episodes of abrupt terror arousals from sleep, usually beginning with a panicky scream.
  • There is intense fear and signs of autonomic arousal, such as mydriasis, tachycardia, rapid breathing, and sweating, during each episode.
  • There is relative unresponsiveness to efforts of others to comfort the individual during the episodes.
  • No or little (e.g., only a single visual scene) dream imagery is recalled.
  • C. Amnesia for the episodes is present.
  • D. The episodes cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication).
  • F. Coexisting mental and medical disorders do not explain the episodes of sleepwalking or sleep terrors.
    • New DSM-5 Diagnosis
    • Recurrent episodes of either/or:
      • Sleep terrors
        • Recurrent episodes of panic-like symptoms during non-REM sleep
      • Sleepwalking – Sleepwalking episodes may range from sitting up and attempting to walk to conducting an involved sequence of semipurposeful actions.
      • Characteristically begin toward the end of the first or second slow wave sleep episodes.
      • Sleep deprivation and interruption of slow wave sleep appear to exacerbate, or even provoke, sleepwalking in susceptible individuals.
    • Individual has no memory of the episodes
    • More common in children (~6%) than adults
    • Child cannot be easily awakened during the episode
    • Child has little memory of it the next day
  • Sleep walking disorder – somnambulism
    • Occurs during non-REM sleep
    • Usually during first few hours of deep sleep
    • Person must leave the bed
    • More common in children than adults
    • Problem usually resolves on its own without treatment
    • Seems to run in families
    • May be accompanied by nocturnal eating

Nightmare Disorder

  • Repeated episodes of extended, extremely dysphoric dreams leading to distress and/or impairment in daily life
    • Not adequately explained by other conditions
    • 10%-50% of children and 1% of adults have nightmares
    • Occurs during REM sleep
    • Dreams often awaken the sleeper
    • Problem is more common in children than adults
  • REM Sleep Behavior Disorder
    • New diagnosis in DSM-5
  • Repeated episodes of arousal during sleep associated with vocalization and/or complex motor behaviors
  • Causes impairment or distress
    • Often, major problem is injury to self or sleeping partner

Treatment for Parasomnias

  • Parasomnias may go away on their own
  • Reducing nightmares
    • Cognitive behavioral therapy
    • Drugs such as prazosin may help
    • Relaxation may help
  • Reducing sleep terrors
    • Scheduled awakenings: Wake child up before sleep terror usually occurs, then fade out awakenings over time

Somatic symptom disorders

  • All of the above mentioned disorders share a common feature – The prominence of somatic symptoms associated with significant distress and impairment.
  • People with this disorder are commonly encountered in primary care and other medical settings but are less commonly encountered in psychiatric and other mental health settings.
  • The major diagnosis in this diagnostic class, somatic symptom disorder, emphasizes diagnosis made on the basis of positive symptoms and signs (distressing somatic symptoms plus abnormal thoughts, feelings, and behaviors in response to these symptoms) rather than the absence of medical explanations for somatic symptoms.
  • A distinctive characteristic of many individuals with somatic symptom disorder is not the somatic symptoms per se, but instead the way they present and interpret them. Incorporating affective, cognitive and behavioral components into the criteria for somatic symptom disorder provides a more comprehensive and accurate reflection of the true clinical picture than can be achieved by assessing the somatic complaints alone.

Primary Somatic Symptom Disorders

  • Somatic symptom disorder. Formerly called somatization disorder, this chronic condition is characterized by unexplained physical symptoms. It is found almost exclusively in women
  • Somatic symptom disorder, with predominant pain. The pain in question has no apparent physical or physiological basis, or it far exceeds the usual expectations, given the patient’s actual physical condition.
  • Conversion disorder (functional neurological symptom disorder). These patients complain of isolated symptoms that seem to have no physical cause.
  • Illness anxiety disorder. Formerly called hypochondriasis, this is a disorder in which physically healthy people have an unfounded fear of a serious, often life-threatening illness such as cancer or heart disease—but little in the way of somatic symptoms.
  • Psychological factors affecting other medical conditions. A patient’s mental or emotional issues influence the course or care of a medical disorder.
  • Factitious disorder imposed on self. Patients who want to occupy the sick role (perhaps they enjoy the attention of being in a hospital) consciously fabricate symptoms to attract attention from health care professionals.
  • Factitious disorder imposed on another. A person induces symptoms in someone else, often a child, possibly for the purpose of gaining attention.

Somatic symptom disorders

  • Earlier called Hypochondriasis
  • Individuals must be experiencing chronic somatic symptoms that are distressing to them.
  • They must also be experiencing dysfunctional thoughts, feelings and/or behaviors.
  • Characterized by 6 or more months of a general and non-delusional preoccupation with fears of having, or the idea that one has, a serious disease based on the person’s misinterpretation of bodily symptoms.

Clinical / Diagnostic Features

  1. Pain and symptoms may be specific
  2. Although sometimes only one severe symptom, most commonly is pain, is present.
  3. Symptoms may be specific (e.g., localized pain) or relatively nonspecific (e.g., fatigue).
  4. The symptoms sometimes represent normal bodily sensations or discomfort that does not generally signify serious disease.
  5. Somatic symptoms without evident medical explanations are not sufficient to make this diagnosis. The individual’s suffering is authentic, whether or not it is medically explained.
  • Not mutually exclusive
  •  The symptoms may or may not be associated with another medical condition
  • The diagnoses of somatic symptom disorder and a concurrent medical illness are not mutually exclusive, and these frequently occur together.
  • For example, an individual may become seriously disabled by symptoms of somatic symptom disorder after an uncomplicated myocardial infraction even if the myocardial infraction itself did not result in any disability.
  • If another medical condition or high risk for developing one is present (e.g., strong family history), the thoughts, feelings, and behaviors associated with this condition are excessive.
  • High level of anxiety
  • Individuals with SSD tend to have very high levels of worry about illness.
  • They appraise their bodily symptoms as unduly threatening, harmful, or troublesome and often think the worst about their health.
  • Even when there is evidence to the contrary, some patients still fear the medical seriousness of their symptoms.
  • In severe SSD, health concerns may assume central role in the individual’s life, becoming a feature of his or her identity and dominating interpersonal relationships.
  • In relation to other aspects of lives or deny any source
  • When asked directly about their distress, some individuals describe it in relation to other aspects of their lives, while others deny any source of distress physically and mentally.
  • Health – related quality of life is often impaired, both and when persistent, the disorder can lead to invalidism.
  • Medical care
  • Often a high level of medical care utilization, which rarely alleviates the individual’s concerns.
  • Consequently, the patient may seek care from multiple doctors for the same symptoms.
  • These individuals often seem unresponsive to medical interventions and new interventions may only exacerbate the presenting symptoms.
  • Some individuals with the disorder seem unusually sensitive to medication side effects.
  • Some feel that their medical assessment and treatment has been inadequate.
  • Cognitive features
  • Attention focused on somatic symptoms
  • Attribution of normal bodily sensations to physical illness (possibly with catastrophic interpretations)
  • Worry about illness
  • Fear that any physical activity may damage the body.
  • Behavioral features
  • Repeated bodily checking for abnormalities
  • Repeated seeking of medical help and reassurance
  • Avoidance of physical activity

These features are usually associated with frequent requests to medical help for different somatic symptoms. This may lead to medical consultations in which individuals are so focused on their concerns about somatic symptoms that they cannot be redirected to other matters.

Any reassurance by the doctor that the symptoms are not indicative of serious physical illness tends to be short – lived and / or is experienced by the individuals as the doctor not taking their symptoms with due seriousness.

  • Primary symptom
  • Individuals with SSD typically present to general medical health services rather than mental health services. The suggestion of referral to a mental health specialist may be met with surprise or even frank refusal by the individual.
  1. Suicide risk
  2. Since SSD is associated with depressive disorders, there is an increased suicide risk.


  • A. One or more somatic symptoms that are distressing or result in significant disruption of daily life.
  • B. Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following:
  • 1. Disproportionate and persistent thoughts about the seriousness of one’s symptoms.
  • 2. Persistently high level of anxiety about health or symptoms.
  • 3. Excessive time and energy devoted to these symptoms or health concerns.
  • C. Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months).
  • Associated features
    • Cognitive features include attention focused on somatic symptoms, attribution of normal bodily sensations to physical illness (possibly with catastrophic interpretations), worry about illness, and fear that any physical activity may damage the body.
    • The relevant associated behavioral features may include repeated bodily checking for abnormalities, repeated seeking of medical help and reassurance, and avoidance of physical activity.
    • This may lead to medical consultations in which individuals are so focused on their concerns about somatic symptom(s) that they cannot be redirected to other matters.

Causes- cognitive behavioral 

  • People with SSD tend to have a cognitive style that leads them to be hypersensitive to their bodily sensations.
  • They also experience these sensations as intense, disturbing and highly aversive.
  • Another characteristic of such patients is that they tend to think catastrophically about their symptoms, often overestimating the medical severity of their condition.


  • Somatic symptom disorder can also be understood in terms of a social learning model.
  • The symptoms of this disorder are viewed as a request for admission to the sick role made by a person facing seemingly insurmountable and in solvable problems.
  • The psychodynamic school of thought holds that aggressive and hostile wishes toward others are transferred (through repression and displacement) into physical complaints.
  • In children, most common symptoms are recurrent abdominal pain, headache, fatigue, and nausea.
  • A single prominent symptom is more common in children that in adults.
  • While young children may have somatic complaints, they arely worry about “illness” pe se prior to adolescence.
  • The parents’ response to the symptom is important, as this may determine the level of associated distress.
  • It is the parent who may determine the interpretation of symptoms and the associated time off school and medical help seeking.

The course of the disorder is usually episodic; the episodes last from months to years and are separated by equally long quiescent periods. There may be an obvious association between exacerbations of somatic symptoms and psychosocial stressors.

Risk and Prognostic Factors

  1. Temperamental
  2. The personality trait of negative affectivity (neuroticism) has been identified as an independent correlate/ risk factor of a high number of somatic symptoms.
  3. Comorbid anxiety or depression is common and may exacerbate symptoms and impairment
  • Environmental
  • SSD is more frequent in individuals with few years of education and low socioeconomic status, and in those who have recently experienced stressful life events.
  • Course modifiers
  • Persistent somatic symptoms are associated with demographic features
    • Female sex
    • Older age
    • Fewer years of education
    • Lower socioeconomic status
    • Unemployment
  • A reported history of sexual abuse or other childhood adversity
  • Concurrent chronic physical illness or psychiatric disorder
    • Depression
    • Anxiety
    • Persistent depressive disorder (dysthymia)
    • Panic
  • Social stress and reinforcing social factors such as illness benefits.
  • Cognitive factors that affect clinical course include
  • sensitization to pain
  • heightened attention to bodily sensations
  • Attributions of bodily symptoms to a possible medical illness rather than recognizing them as normal phenomenon or psychological stress.

Culture – related Diagnostic Issues

  1. Population and case studies
  2. High numbers of somatic symptoms are found in population – based and primary case studies around the world, with a similar pattern of the most commonly reported somatic symptoms, impairment, and treatment seeking.
    1. Relationship between
  3. The relationship between number of somatic symptoms and illness worry is similar in different cultures, and marked illness worry is associated with impairment and greater treatment seeking across cultures.
  4. The relationship between numerous somatic symptoms and depression appears to be similar around the world and between different cultures within one country.
    1. Linguistic and local cultural factors
  5. The description of somatic symptoms varies with linguistic and other local cultural factors.
  6. These somatic presentations have been described as “idioms of distress” because somatic symptoms may have special meanings and shape patient – clinician interactions in the particular cultural contexts.
  7. “Burnout,” the sensation of heaviness or the complaints of “gas”; too much heat in the body; or burning in the head are examples of symptoms that are common in some cultures or ethnic groups but rare in others.
  8. Explanatory models also vary, and somatic symptoms may be attributed variously to particular family, work, or environmental stresses; general medical illness; the suppression of feelings of anger and resentment; or certain cultural – specific phenomena, such as semen loss.
    1. Seeking treatment
  9. Seeking treatment for multiple somatic symptom in general medical clinics is a worldwide phenomenon and occurs at similar rates among ethnic groups in the same country.
  10. This disorder is also viewed as a defense against guilt, a sense of innate badness, an expression of low self-esteem, and a sign of excessive self-concern
  11. Symptoms are maintained by secondary reinforcements.
  12. These people also tend to have an excessive amount of illness in their families while growing up, which may lead to strong memories of being sick or in pain or of having observed some of the secondary benefits that sick people sometimes get.

 Illness anxiety disorder

Clinical / Diagnostic Features

  • IAD entails a preoccupation with having or acquiring a serious, undiagnosed medical illness (Criterion A)
  • Somatic symptoms are not present or, if present, are only mild in intensity (Criterion B).
  • A thorough evaluation fails to identify a serious medical condition that accounts for the individual’s concerns.
    • While the concern may be derived from a nonpathological physical sign or sensation, the individual’s distress emanates not primarily from the physical complaint itself but rather from his or her anxiety about the meaning, significance, or cause of the complaint (i.e., the suspected medical diagnosis).
  • If a physical sign or symptom is present, it is often a normal physiological sensation (e.g., orthostatic dizziness), a benign and self –limited dysfunction (e.g., transient tinnitus), or bodily discomfort not generally considered indicative of the disease (e.g., belchtinnitus).
  • If a diagnosable medical condition is present, the individual’s anxiety and preoccupation are clearly excessive and disproportionate to the severity of the condition (Criterion B)
  • The preoccupation with the idea that one is sick is accompanied by substantial anxiety about the health and disease (Criterion C).
    • Individuals with IAD are easily alarmed about illness, such as by hearing about someone else falling ill or reading a health related news story.
    • Their concerns about undiagnosed disease do not respond to appropriate medical reassurance, negative diagnostic tests, or benign course.
    • The physician’s attempts at reassurance and symptom palliation generally do not alleviate the individual’s concerns and may heighten them.
  • Illness concerns assume a prominent place in the individual’s life, affecting daily activities, may even result in invalidism.
  • Illness becomes a central feature of the individual’s identity and self – image, a frequent topic of social discourse, and a characteristic response to stressful life events.
  • Individuals with the disorder often examine themselves repeatedly (e.g., examining one’s throat in the mirror)(Criterion D)
  • They research their suspected disease excessively (e.g., on the Internet) and repeatedly seek reassurance from family, friends, or physicians.
    • This incessant worrying often becomes frustrating for others and may result in considerable strain within the family.
  • In some cases, the anxiety leads to maladaptive avoidance of situations (e.g., visiting sick family members) or activities (e.g., exercise) that these individuals fear might jeopardize their health.

Associated features supporting diagnosis

  • Because they believe they are medically ill, individuals with illness anxiety disorder are encountered far more frequently in medical than in mental health settings.
  • The majority of individuals with illness anxiety disorder have extensive yet unsatisfactory medical care though some may be too anxious to seek medical attention.
    • They generally have elevated rates of medical utilization but do not utilize mental health services more than the general population.
    • They often consult multiple physicians for the same problem and obtain repeatedly negative diagnostic test results.
  • At times, medical attention leads to paradoxical exacerbation of anxiety or to iatrogenic complications from diagnostic tests and procedures.
  • Individuals with the disorder are generally dissatisfied with their medical care and find it helpful; often feeling they are not being taken seriously by physicians.

Development and Course

  • The development and course of IAD are unclear.
  • Age
    • IAD is generally thought to be chronic and relapsing condition with an age at onset in early and middle adulthood.
    • In population – based samples, health – related anxiety increase with age, but the ages of individuals with high health anxiety in medical settings do not appear to differ from those of other patients in those settings.
    • In older individuals, health – related anxiety often focuses on memory.
    • The disorder is thought to be rare in children.

Risk and Prognostic Factors

  • Environmental
    • IAD may sometimes be precipitated by a major life stress or a serious but ultimately benign threat to individual’s health.
    • A history of childhood abuse or if a serious childhood illness may predispose to development of the disorder in adulthood
  • Course modifiers
    • Approximately one – third to one – half of the individuals with IAD have a transient form, which is associated with less psychiatric comorbidity, a=more medical comorbidity, and less severe IAD.

Functional Consequences of IAD

  • IAD causes substantial role impairment and decrements in physical function and health related – quantity of life.
  • Health concerns often interfere with interpersonal relationships, disrupt family, and damage occupational performance.


  • A. Preoccupation with having or acquiring a serious illness.
  • B. Somatic symptoms are not present or, if present, are only mild in intensity. If another medical condition is present or there is a high risk for developing a medical condition (e.g., strong family history is present), the preoccupation is clearly excessive or disproportionate.
  • C. There is a high level of anxiety about health, and the individual is easily alarmed about personal health status.
  • D. The individual performs excessive health-related behaviors (e.g., repeatedly checks his or her body for signs of illness) or exhibits maladaptive avoidance (e.g., avoids doctor appointments and hospitals).
  • E. Illness preoccupation has been present for at least 6 months, but the specific illness that is feared may change over that period of time.
  • F. The illness-related preoccupation is not better explained by another mental disorder, such as somatic symptom disorder, panic disorder, generalized anxiety disorder, body dysmorphic disorder, obsessive-compulsive disorder, or delusional disorder, somatic type.
  • The majority of individuals with illness anxiety disorder have extensive yet unsatisfactory medical care, though some may be too anxious to seek medical attention.
  • They often consult multiple physicians for the same problem and obtain repeatedly negative diagnostic test results.
  • The individual performs excessive health-related behaviors (e.g., repeatedly checks his or her body for signs of illness) or exhibits maladaptive avoidance (e.g., avoids doctor appointments and hospitals).
  • They are sincere in their convictions that the symptoms they detect represent real illness.
  • They are not malingering- consciously faking symptoms to achieve specific goals such as winning a personal injury lawsuit.
  • Individual’s past experiences with illnesses lead to the development of a set of dysfunctional assumptions about symptoms & diseases that may predispose a person to develop the disorder.
  • They seem to believe that being healthy means being completely symptom-free.
  • They perceive their symptoms as more dangerous than it really is.
  • Once they have misinterpreted the symptom, they look for confirming evidence and to discount evidence that they are in good health.
  • These patients reported much childhood sickness & missing of school, in terms of secondary reinforcements.


The etiology is unknown.

  • Social learning model
    • The fear of illness is viewed as a request to play the sick role made by someone facing seemingly insurmountable and insolvable problems.
    • The sick role offers an escape that allows a patient to be excused from usual duties and obligations.
  • Psychodynamic school of thought
    • Aggressive and hostile wishes toward others are transferred into minor physical complaints or the fear of physical illness.
    • The anger of patients with illness anxiety disorder, as in those with hypochondriasis, originates in past disappointments, rejections, and losses.
    • Similarly, the fear of illness is also viewed as a defence against guilt, a sense of innate badness, an expression of low self-esteem, and a sign of excessive self-concern.
    • The feared illness may also be seen as punishment for past either real or imaginary wrongdoing.
    • The nature of the person’s relationships to significant others in his or her past life may also be significant.
    • A parent who died from a specific illness, for example, might be the stimulus for the fear of developing that illness in the offspring of that parent.
    • The type of the fear may also be symbolic of unconscious conflicts that are reflected in the type of illness of which the person is afraid or the organ system selected (e.g., heart, kidney).

Conversion disorder (functional neurological symptom disorder)

  • Many clinicians use the alternative names of “functional”(referring to abnormal central nervous system functioning) or “psychogenic” (referring to an assumed etiology) to describe the symptoms of conversion disorder (functional neurological symptom disorder).
  • It is characterized by the presence of neurological symptoms in the absence of neurological diagnoses.
  • The patient has symptoms or deficits affecting the senses or motor behavior that strongly suggest a medical or neurological condition.

Diagnostic features / Clinical features

  • Motor symptoms
    • Weakness or paralysis
    • Abnormal movements
      • Tremors
      • Dystonic movements
      • Gait abnormalities
      • Abnormal limb posturing
  • Sensory symptoms
    • Altered , reduced, or absent skin sensation
    • Vision or hearing
  • Episodes of abnormal generalized limb shaking with apparent impaired or loss of consciousness0 may resemble epileptic seizures (also called psychogenic or non – epileptic seizures)
  • There may be episodes of unresponsiveness resembling coma or syncope.
  • Other symptoms include
    • Reduced or absent speech volume
      • Dysphonia / Aphonia
  • Altered articulation
  • Dysarthria
  • A sensation of lump in the throat
    • Globus
  • Diplopia
  • Although the diagnosis requires that the symptom is not explained by neurological disease, it should not be made simply because results from investigations are normal or because the symptom is “bizarre”.
  • There must be clinical findings that show clear evidence of incompatibility with neurological disease.
  • Internal consistency at examination is one way to demonstrateincompatibility (i.e., demonstrating that physical signs elicited through one examination method are no longer positive when tested a different way).


  • A. One or more symptoms of altered voluntary motor or sensory function.
  • B. Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions.
  • C. The symptom or deficit is not better explained by another medical or mental disorder.
  • D. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.
  • “functional” (referring to abnormal central nervous system functioning) or “psychogenic” (referring to an assumed etiology) to describe the symptoms of conversion disorder (functional neurological symptom disorder).
  • There may be one or more symptoms of various types.
  • Motor symptoms include weakness or paralysis; abnormal movements, such as tremor or dystonic movements; gait abnormalities; and abnormal limb posturing.
  • The movements generally worsen when attention is called to them.
  • One gait disturbance seen in conversion disorder is astasia-abasia, which is a wildly ataxic, staggering gait accompanied by gross, irregular, jerky  movements and thrashing and waving arm movements.
  • Patients with the symptoms rarely fall; if they do, they are generally not injured.
  • Sensory symptoms
    • Symptoms in the affected area are inconsistent with how known natomical sensory pathways operate.
    • Sensory symptoms include altered, reduced, or absent skin sensation (Anesthesia and paresthesia) vision (blindness and tunnel vision) or hearing (deafness).
    • In the anesthesias, the person loses his sense of feeling in a part of the body.
    • Glove anesthesia of the hands (the person cannot feel anything on the hand in the area where gloves are worn, although the loss of sensation makes no anatomical sense.
    • In conversion disorder blindness, the person reports that he cannot see, but walk around without collisions or self-injury, their pupils react to light, and their cortical-evoked potentials are normal.
    • With conversion deafness, he reports not being able to hear and yet orients appropriately upon hearing his name.
    • Sensory input is registered but is somehow screened from explicit conscious recognition.
  • Motor symptoms
    • Conversion paralysis is confined to a single limb such as an arm or leg.
    • A person may not be able to write but may be able to use the same muscles for scratching, or a person may not be able to walk most of the time but may be able to walk in an emergency such as a fire where escape is important.
    • There may be episodes of unresponsiveness resembling syncope or coma.
  • Other speech related symptoms include
    • Aphonia (person is able to talk only in a whisper although he can cough in a normal manner), reduced or absent speech volume (dysphonia/aphonia), altered articulation (dysarthria), and a sensation of a lump in the throat (globus.
    • Seizures
    • These resemble epileptic seizures.
    • Patients do not show any EEG abnormalities and do not show confusion and loss of memory afterward, as patients with true epileptic seizures.
    • They often show excessive thrashing about and writhing not seen with true seizures.
    • They rarely injure themselves in falls or lose bowel or bladder control.
  • History
    • Freud suggested that most people with conversion disorder showed very little of the anxiety & fear that would be expected in a person with paralyzed arm or loss of sight, which was known as la belle indifference.
    • Historically, this disorder was grouped under the term, hysteria.
    • But Freud used the term conversion disorder because he believe that the symptoms were an expression of repressed sexual energy.
  • Associated features
    • There may be a history of multiple similar somatic symptoms.
    • Onset may be associated with stress or trauma, either psychological or physical in nature.
    • The potential etiological relevance of this stress or trauma may be suggested by a close temporal relationship
  • Malingering and factitious disorders
    • Malingering: person intentionally produces or grossly exaggerates physical symptoms and is motivated by external incentives such as avoiding work or obtaining financial compensation.
    • Factitious disorder: person intentionally produces or grossly exaggerates physical symptoms but there are no external incentives.
    • The person’s goal is to obtain and maintain the personal benefits that playing the sick ole may provide including the attention and care of family.
  • Issues in diagnosing conversion disorder
    • Accurate diagnosis is difficult- symptoms can stimulate a variety of medical conditions.
    • Criteria to distinguish conversion from true neurological disturbances: a, the frequent failure of the dysfunction to conform clearly to the symptoms of the particular disease stimulated.
    • E.g., little or no atrophy of a paralyzed limb occurs in conversion paralysis
    • The nature of the dysfunction is highly selective.
    • Under hypnosis or narcosis, the symptoms can usually be removed, shifted or reinduced at the suggestion of therapist


  • Psychoanalytic Factors
    • According to psychoanalytic theory, conversion disorder is caused by repression of unconscious intrapsychic conflict and conversion of anxiety into a physical symptom.
    • The conflict is between an instinctual impulse (e.g., aggression or sexuality) and the prohibitions against its expression.
    • The symptoms allow partial expression of the forbidden wish or urge but disguise it, so that patients can avoid consciously confronting their unacceptable impulses; that is, the conversion disorder symptom has a symbolic relation to the unconscious conflict—for example, veganism’s protects the patient from expressing unacceptable sexual wishes.
  • Learning Theory
    • In terms of conditioned learning theory, a conversion symptom can be seen as a piece of classically conditioned learned behavior; symptoms of illness, learned in childhood, are called forth as a means of coping with an otherwise impossible situation.
  • Biological Factors
    • Increasing data implicate biological and neuropsychological factors in the development of conversion disorder symptoms.
    • Preliminary brain-imaging studies have foundhypo metabolism of the dominant hemisphereand hyper metabolism of the non-dominant hemisphere and have implicated impaired hemispheric communication in the cause ofconversion disorder.
    • The symptoms may be caused by an excessive cortical arousal thatsets offnegative feedback loops between the cerebral cortex and the brainstem reticular formation.
    • Elevated levels of corticofugal output, in turn, inhibit the patient’s awarenessof bodily sensation, which may explain the observed sensory deficits in some patientswith conversion disorder.
    • Neuropsychological tests sometimes reveal subtle cerebralimpairments in verbal communication, memory, vigilance, affective incongruity, and attention in these patients.

Development and Course

  • Onset has been reported throughout the life course.
  • The onset of non – epileptic attacks peaks in the third decade, and motor symptoms, have their peak onset in the fourth decade.
  • The symptoms can be transient or persistent.
  • The prognosis may be better in younger children than in adolescents and adults.

Risk and Prognostic Factors

  • Temperamental
    • Maladaptive personality traits are commonly associated with CD
  • Environmental
    • There may be a history of childhood abuse and neglect.
    • Stressful life events are often, but not always, present.
  • Genetic and physiological
    • The presence of neurological disease that causes similar symptoms is a risk factor (e.g., non – epileptic seizures are more common in patients who also have epilepsy).
  • Course modifiers
    • Short duration of symptoms and acceptance of the diagnosis are positive prognostic factors.
    • Maladaptive personality traits, the presence of comorbid physical disease, and the receipt of disability benefits may be negative prognostic factors.

Cultural – related diagnostic issues

  • Changes resembling conversion (and dissociative) symptoms are common in certain culturally sanctioned rituals.

Dissociative disorders

  • The critical component is a disturbance in functioning of consciousness, memory, identity, or perception of the environment.
    • The disturbance may be sudden or gradual transient or chronic.

Dissociative amnesia

  • Criteria
  • A. A. An inability to recall important autobiographical information, usually of a traumatic or stressful nature, that is inconsistent with ordinary forgetting.
  • Note: Dissociative amnesia most often consists of localized or selective amnesia for a specific event or events; or generalized amnesia for identity and life history.
  • B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • C. The disturbance is not attributable to the physiological effects of a substance (e.g., alcohol or other drug of abuse, a medication) or a neurological or other medical condition (e.g., partial complex seizures, transient global amnesia, sequelae of a closed head injury/ traumatic brain injury, other neurological condition).
  • D. The disturbance is not better explained by dissociative identity disorder, posttraumatic stress disorder, acute stress disorder, somatic symptom disorder, or major or mild neurocognitive disorder.
  • With dissociative fugue: Apparently purposeful travel or bewildered wandering that is associated with amnesia for identity or for other important autobiographical information

Clinical features

  • The patient is brought to quick medical attention due to obvious, elaborate and dramatic clinical disturbance
  • Localized amnesia: Inability to remember a specific period of time, or a specific event, or a circumscribed period of time.
  • Selective amnesia: Inability to remember some, but not all, of the events during a circumscribed period of time.
  • Systematized amnesia. Inability to remember certain categories of memory
  • Continuous amnesia: Inability to remember successive events as they occur (i.e. ongoing anterograde dissociative amnesia); extremely rare; may present as dissociative pseudo-delirium, pseudodementia, or pseudo-amnestic-confabulatory syndrome
  • Generalized (global) amnesia: Forgetting one’s entire life, generally including memory for personal identity
  • Fugue
    • Sometimes, an individual may go through an amnestic state where they may forget some or all aspects of their past and run away from their home. This is called as dissociative fugue.
    • After the amnestic state is over the individual may be confused about their personal identity
    • Memory may suffer
    • Behavior during the fugue state is quite normal and unlikely to arouse suspicion that something is wrong.
  • Causes
    • Psychodyanmic theory: their home and surrounding environment is usually conflictual, with the patient experiencing intolerable amounts of negative emotions such as shame, guilt, despair, rage, & desperation.
      • Conflicts may also rise due to repressed sexual or unacceptable urges or impulses.


  • Cognitive therapy: Cognitive distortions related to the trauma may help in clearing the confused state.
  • Hypnosis: is often used to regulate the intensity of symptoms. They are also used to recall of dissociated memories, to provide support and ego strengthening for the patient.
  • Group psychotherapy are known to help as well.
    • Interventions by the group members or the group therapist, or both, may facilitate integration and mastery of the dissociated material.

Depersonalization/Derealization disorder

  • Patients experience themselves as strange or unreal in some way.
  • They feel detached from their surroundings as if someone else is ‘in control’ or as if they are living in a dream or moving in slow motion.
  • The individual remains in touch with reality, but the symptoms may be persistent, recurrent & seriously impair functioning.
  • They would explain the situation as if they seem to be observing things rather than actually participating in them.

Depersonalization disorder


  • The presence of persistent or recurrent experiences of depersonalization, derealization,or both:
    • Depersonalization: Experiences of unreality, detachment, or being an outside observer with respect to one’s thoughts, feelings, sensations, body, or actions (e.g., perceptual alterations, distorted sense of time, unreal or absent self, emotional and/ or physical numbing).
    • Derealization: Experiences of unreality or detachment with respect to surroundings (e.g., individuals or objects are experienced as unreal, dreamlike, foggy, lifeless,or visually distorted).
  • During the depersonalization or derealization experiences, reality testing remains intact
  • C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • D. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, medication) or another medical condition (e.g., seizures).
  • E. The disturbance is not better explained by another mental disorder, such as schizophrenia, panic disorder, major depressive disorder, acute stress disorder, posttraumatic stress disorder, or another dissociative disorder.

Clinical features

  • The individual feels disconnected from their body and feels that they are themselves as well the observer and have no sense of their emotions.


  • Psychodynamic: Ego Disintegration is a response to protecting one’s ego incase of unacceptable anxieties or conflicts.
  • Trauma: Any form of trauma can lead to stress which can lead to feeling symptims of depersonalization or derealisation.
  • Neurobiological theories: serotonin involvement and NMDA(N-Methyl-D-aspartate) subtype of the glutamate receptor abnormality are central to the genesis of depersonalization disorder


  •  Medical: antidepressants, mood stabilizers, typical neuroleptics, anticonvulsants.
  • Psychodynamic, cognitive, cognitive-behavioral, hypnotherapeutic & supportive psychotherapy are effective.
  • Stress management strategies, distraction techniques, reduction of sensory stimulation, relaxation training, & physical exercise are also helpful

Dissociative identity disorder


  • A. Disruption of identity characterized by two or more distinct personality states, which may be described in some cultures as an experience of possession.
  • The disruption in identity involves marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning. These signs and symptoms may be observed by others or reported by the individual.
  • B. Recurrent gaps in the recall of everyday events, important personal information, and/ or traumatic events that are inconsistent with ordinary forgetting.
  • C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • D. The disturbance is not a normal part of a broadly accepted cultural or religious practice.
  • Note: In children, the symptoms are not better explained by imaginary playmates or other fantasy play.
  • E. The symptoms are not attributable to the physiological effects of a substance (e.g., blaclkouts or chaotic behavior during alcohol intoxication) or another medical condition (e.g., complex partial seizures).
  • Trance state: when someone experiences a temporary marked alteration in state of consciousness or identity.
  • Possession trance: alteration in state of consciousness or identity is replaced by a new identity that is attributed to the influence of a deity, spirit or other power.
  • When they occur involuntarily outside accepted cultural contexts and cause distress, it is pathological.
  • Different personalities emerge and are apparent to an outside observer.
  • Each identity appear to have a different personal history, self-image, and name, although there may be some identities that are only partially distinct and independent from other identities.
  • The identity that is most frequently encountered and carries the person’s real name is the host identity.
  • The alter identities may differ in striking ways involving gender, age, handedness, handwriting, sexual orientation, prescription for eyeglasses, predominant affect, foreign languages spoken, and general knowledge.
  • Needs and behaviors inhibited in the primary or host identity are usually liberally displayed by one or more alter identities.
  • These identities reflect a failure to integrate various aspects of a person’s identity, consciousness, and memory

Clinical features

  • The patient is usually seen to have mood swings, depression, suicidal tendencies, & generalized irritability
  • Impulse control is impaired, leading to risk taking, substance abuse, & inappropriate or self-destructive behaviors.
  • Autobiographical memory suffers.
  • Routinely refer to themselves in third or first person
  • They may refer to themselves using their own first names or make depersonalized self-references, such as ‘the body’, when describing themselves & others
  • They may show internal conflicts between parts of themselves.


  • Children who are abused are at risk for developing dissociative symptoms
  • Trauma can create a need to dissociate as the conflicts are too strong to deal
  • Epileptic-and-Limbic System Model: epileptiform discharges and unusually high rates of left temporal lobe EEG abnormalities have been reported
  • Social role model: socially induced behavior that arises through the effects of implicit or explicit suggestion by an authority figure such as a therapist on a susceptible patient.
  • The behavioral state model conceptualizes the disorder as a developmental failure by a traumatized child to consolidate a core sense of identity


  • Psychotherapy: psychoanalytic psychotherapy, cognitive-behavioral therapy, hypnotherapy etc are used.
  • Hypnotherapeutic interventions are used and reduce self-destructive impulses or reduce symptoms such as flashbacks, dissociative hallucinations, and passive-influence experiences
  • Art therapy aids to safely express thoughts, feelings, mental images, and conflicts that they have difficulty verbalizing.
  • Movement therapy may facilitate normalization of body image for these severely traumatized patients.
  • Family therapy with the family of origin of the dissociative patient may be helpful in clarifying on resolving the conflictual emotions these patients frequently experience towards family members

Dissociative disorder not otherwise specified

  • Dissociative trance disorder: a temporary, marked alteration in the state of consciousness or by loss of the customary sense of identity without the replacement by an alternate sense of identity.
    • A narrowing of awareness of the immediate surroundings with stereotypical behaviors or movements that are experienced as involuntary and for which there may be partial or total amnesia
  • Possession trance involves single or episodic alternations in the state of consciousness, characterized by the exchange of the person’s customary identity by a new identity usually attributed to a spirit, divine power, deity or another person.
  • Brain washing: “states of dissociation that occur in individuals who have been subjected to periods of prolonged and intense coercive persuasion.
  • People submitted to such conditions can undergo considerable harm, including loss of health and life, and typically manifest a variety of posttraumatic and dissociative symptoms
  • Coercive processes has been linked to the artificial creation of an identity crisis, with the emergence of a new pseudoidentity that manifests characteristics of a dissociative state

Schizophrenia Spectrum and Other Psychotic Disorders

            Contributed by: Ms. Aishwarya Thakur

  • Psychosis: significant loss of contact with including:
    • Hallucinations: Sensory experiences in the absence of sensory input (e.g. hearing voices)
    • Delusions: Strong, inaccurate beliefs that persist in the face of evidence to the contrary
  • Schizophrenia is a pervasive type of psychosis characterized by disturbed thought, emotion, and behavior.
  • Nature of Schizophrenia and Psychosis: History and Current Thinking
  • Historical background

Symptoms of Schizophrenia

  • “Positive” symptoms:
    • Active manifestations of abnormal behavior
    • Distortions or exaggerations of normal behavior
  • “Negative” symptoms:
    • Absence of normal behavior
  • “Disorganized” symptoms:
    • Erratic speech, emotions and behavior
    • Schizophrenia: The “Positive” Symptom Cluster
  • Delusions (disorder of thought content): false firm fixed belief that is held despite clear contradictory evidence and is not in keeping with the person’s socio-cultural & educational background. Types of delusions common in schizophrenia are:
  • Delusions of persecution: belief of being persecuted against. E.g. people are against me.
  • Delusions of reference: being referred to by others. E.g. people are talking about me.
  • Delusions of grandeur: exaggerated sense of self-importance. E.g. I am God almighty.
  • Delusions of control: belief of being controlled by an external force known or unknown. E.g. my neighbor is controlling me. 
  • Somatic(or hypochondriacal) delusions: E.g. there are insects crawling in my scalp.


A. Two or more of the following symptoms, present during a significant portion of time during a 1-month period (less if successfully treated):

(1) Delusions

(2) Hallucinations

(3) Disorganised Speech

(4) Grossly disorganized or catatonic behavior

(5) Negative symptoms         

B. Dysfunction in work, interpersonal relations or self care.

C. Signs of disturbance for atleast 6 months, with at least 1 month of symptoms listed above.

Schizophrenia: The “Positive” Symptom Cluster

  • Hallucinations are sensory experiences of events without environmental input
    • Hallucinations are most common for audition and sight but can involve all senses (e.g., tasting something when not eating, having skin sensations when not being touched)
      • Findings from SPECT studies
        • Neuroimaging shows that the part of the brain most active during auditory hallucinations is Broca’s area (speech production)    
  • Schizophrenia: The “Negative” Symptom Cluster
    • Absence or insufficiency of normal behavior
    • Spectrum of negative symptoms
      • Avolition (or apathy) – lack of initiation and persistence
      • Alogia – relative absence of speech
      • Anhedonia – lack of pleasure, or indifference
      • Affective flattening – little expressed emotion
  • Schizophrenia: The “Disorganized” Symptom Cluster
  • Goal directed activity is almost universally disrupted.

Impairment occurs in the areas of work, social relations, self-care.

  • Grimacing, strange facial expressions.
  • Gesture repeatedly using peculiar of complex finger, hand or arm movements; stereotypical behaviour.
  • Decreased self-care, poor grooming, silly dressing sense.
  • Catatonia: extreme behavioural disturbances.
  • May be considered a psychotic spectrum disorder in its own right or, when occurring in the presence of schizophrenia, a symptom of schizophrenia
  • Disorganised speech:
    • Cognitive slippage – illogical and incoherent speech
    • Tangentiality – “going off on a tangent”
    • Loose associations – conversation in unrelated directions
    • Incoherence: speech does not make sense to the listener. Although patient makes repeated references to central ideas, the images or fragments of thought are not connected.
    • Neologisms: new word formation and usage. These are meaningless to the listener. E.g. “prestigitis”. 
    • Word approximation: old words used in a new and unconventional way. E.g. my foodvessel is full.
    • Derailment: (loose associations) ideas slip off the topic’s track on to another which is obliquely related or unrelated. E.g. the nest day I’ll be going out you know, I took control. I put bleach on my hair in California.
    • Word salad: speech that is unintelligible as the manner in which words are strung together results in incoherent gibberish. E.g. why do people comb their hair? Ans: because it makes a twirl in life. Help the hair get elephant.  I love electrons, why not.
    • Poverty of content: amount of speech is adequate, but, it conveys little information because it is vague, overly abstract, repetitive, or stereotyped.
    • Perserveration: words and ideas are persistently repeated. E.g. it’s great to study in Delhi Delhi Delhi.
    • Echolalia: Echoing of another’s speech (words, sentences) that may be committed only once or may be continuous in repetition.
    • Blocking: an abrupt thought in the train of thought; the individual may or may not be able to continue the idea

Subtypes of Schizophrenia: A Thing of the Past

  • Schizophrenia was previously divided in to subtypes based on content of psychosis
  • This is no longer the case in DSM-5, but outdated terms are still in partial use
  • Included paranoid, catatonic, residual (minor symptoms persist after past episode), disorganized (many disorganized symptoms) and undifferentiated
  • Paranoid:
  • Criteria
    • Preoccupation with delusions or frequent auditory hallucinations.
    • No evidence of marked disorganised speech, disorganised or catatonic behaviour, flat or inappropriate affect.
    • History of increasing suspiciousness & severe difficulties in interpersonal relationships.
    • Delusions:
      • persecutory delusions are most frequent. E.g. becoming highly suspicious of relatives, complains of being watched, followed, poisoned etc.
      • delusions of grandeur are also common. E.g. claim to be the greatest person or to have invented an impossible device etc.. In some cases this delusion may provide justification for being persecuted. E.g. I am being spied upon because I am a very important person.
    • Prognosis is better than other types.
  • Disorganised (hebephrenic):
  • Criteria:
    • Disorganised speech
    • Disorganised behaviour
    • Flat or inappropriate affect
    • No evidence of catatonic schizophrenia
    • Gradual insidious onset.
    • Characterised by disorganised speech, disorganised behaviour, flat or inappropriate affect.
    • As the disorder progresses the person becomes more reclusive, preoccupied with fantasy.
    • Infantile behaviour: giggling without apparent reason, baby talk, repetitious use of similar sounding words.
    • Talking & gesturing to oneself, facial grimaces, sudden laughter & weeping.
    • Hallucinations & delusions not coherent & organised.
    • Prognosis: poor.
  • Catatonic:
    • Criteria: clinical picture is dominated by at least two of the following:
    • Immobile body or stupor.
    • Excessive motor activity that is purposeless & unrelated to outside stimuli.
    • Extreme negativism (resistance to being moved or to follow instructions) or mutism.
    • Assumption of bizzare postures or stereotyped movements or mannerisms.
    • Echolalia or echopraxia.
  • Undifferentiated:
    • Criteria: symptoms of schizophrenia that do not meet the criteria for paranoid, disorganised or catatonic types.
    • It’s like a wastebasket category: Delusions, hallucinations, disordered thoughts & bizzare behaviour are present but symptoms don’t fall into one of the other types due to mixed symptom picture.
    • People in early phases of schizophrenic breakdown frequently exhibit undifferentiated symptoms.
  • Residual:
    • Criteria:
    • absence of prominent delusions, hallucinations, disorganised speech & grossly disorganised or catatonic behaviour.
    • Continued evidence of schizophrenia (e.g. negative symptoms) or mild psychotic symptoms (e.g. odd beliefs, unusual perceptual experiences).
    • Those who have undergone at least one episode of schizophrenia but dont show any prominent positive symptoms such as hallucinations, delusions or disorganised speech or behaviour. Although some positive symptoms like odd beliefs may be present in mild form.
    • Mostly negative symptoms: like flat affect etc.

Other Psychotic Disorders: Schizophreniform Disorders

Schizophreniform disorder

  • Criteria
    • Psychotic symptoms lasting between 1-6 months (>6 months = schizophrenia)
    • Associated with relatively good functioning
    • Most patients resume normal lives

Schizoaffective disorder

  • Criteria
    • Symptoms of schizophrenia + additional experience of a major mood episode (depressive or manic)
    • Psychotic symptoms must also occur outside the mood disturbance
    • Prognosis is similar for people with schizophrenia
    • Such persons do not tend to get better on their own

Delusional Disorder

  • Criteria
    • Lack other positive and negative symptoms
    • Types of delusions include
      • Jealous
      • Persecutory
      • Somatic
      • Erotomanic
      • Grandiose
    • Better prognosis than schizophrenia


  • Unusual motor responses, particularly immobility or agitation, and odd mannerisms
  • Tends to be severe and quite rare
  • May be present in psychotic disorders or diagnosed alone, and may include:
    • Repetitive, meaningless motor behaviors
    • Mimicking others’ speech or movement
    • Stupor, mutism, maintaining the same pose for hours
    • Opposition or lack of response to instructions

Psychotic Disorders Due to Other Causes

  • Psychosis may occur as the result of substance use, some medications and some medical conditions
  • Causes is important for treatment inorder to address underlying reasons
    • Include:
      • Substance/medication-induced psychotic disorder
      • Psychotic disorder associated with another medical condition

Brief Psychotic Disorder     

  • Positive symptoms of schizophrenia (e.g., hallucinations or delusions) or disorganized symptoms
  • Lasts less than 1 month
  • Briefest duration of all psychotic disorders
  • Typically precipitated by trauma or stress

Attenuated Psychosis Syndrome    

  • Identified as a condition in need of further study in DSM-5
  • Refers to individuals who are at high risk for developing schizophrenia or beginning to show signs of schizophrenia
  • Label designed to focus attention on these individuals who could benefit from early intervention
  • Tend to have good insight into own symptoms

Schizophrenia: Statistics

  • Onset and prevalence of schizophrenia worldwide
    • About 0.2% to 1.5% (or about 1% population)
    • Often develops in early adulthood
  • Schizophrenia is generally chronic
    • Most suffer with moderate-to-severe lifetime impairment
    • Life expectancy is slightly less than average
      • Increased risk for suicide
      • Increased risk for accidents
      • Self-care may be poorer
  • Schizophrenia affects males and females about equally
    • Females tend to have a better long-term prognosis
    • Onset slightly earlier for males
  • Cultural factors
    • Similar rates in all cultures

Course of Schizophrenia

  • Prodromal phase
    • 85% experience
    • 1-2 years before serious symptoms
    • Less severe, yet unusual symptoms:
      • Illusions
      • Isolation
      • Marked impairment in functioning
      • Ideas of reference
      • Magical thinking
      • Lack of initiative, interests, or energy
  • Causes of Schizophrenia
    • Findings From Genetic Research
    • Family studies
      • There is a strong association between the closeness of the blood relationship and risk for developing schizophrenia.
      • Risk increases with genetic relatedness
        • E.g., having a twin with schizophrenia incurs greater risk than having an aunt with schizophrenia
    • Twin studies
      • Studies have shown a higher concordance for schizophrenia among monozygotic twins over people related in any other way, including dizygotic twins.
      • Monozygotic twins have only about 50% concordance, not 100%. They could differ sometimes because a gene is activated in one and suppressed in another or due to environmental influences.
    • Adoption studies
      • Adoptee risk for developing schizophrenia remains high if a biological parent has schizophrenia
      • But risk is lower than for children raised by their biological parent with schizophrenia – healthy environment is a protective factor
    • Genetic markers: Linkage and association studies
      • Efforts to pin point one gene responsible for schizophrenia have not been successful.
      • It’s believed that as schizophrenia is a spectrum of disorders, probably involves several genes, working together to confer susceptibility to the illness.
    • Behavioral marker (endophenotype): Smooth-pursuit eye movement
      • Schizophrenia patients show reduced ability to track a moving object with their eyes
        • Relatives of schizophrenic patients also have deficits in this area. Maybe an indicator
  • Neurobiological Influences
    • The dopamine hypothesis: schizophrenia is partially caused by overactive dopamine
    • Evidence
      • Drugs that increase dopamine (agonists) result in schizophrenic-like behavior
      • Drugs that decrease dopamine (antagonists) reduce schizophrenic-like behavior
        • Examples – neuroleptics, L-Dopa for Parkinson’s disease
    • Criticism is that this is overly simplistic and most likely that other neurotransmitters are involved.
  • Neurodevelopmental Perspective:
    • Suggests that vulnerability to schizophrenia stems from a brain lesion early in development. This lesion lies dormant until normal maturation of brain, after which problems show up.One speculation is that neuronal migration gets affected due to this.
    • Neurodevelopmental Hypothesis: schizophrenia is based on abnormalities in the prenatal or neonatal development of the nervous system which leads to subtle behaviour.
    • Structural and functional abnormalities in the brain
      • Enlarged ventricles and reduced tissue volume
        • Less active frontal lobes which also forms the dopamine pathway also known as Hypofrontality
    • Viral infections during early prenatal development
      • Findings are inconclusive
    • Marijuana use also increases the risk for developing schizophrenia/psychosis (cannabis induced psychosis) in at-risk individuals
    • Conclusions about neurobiology and schizophrenia
      • Schizophrenia reflects diffuse neurobiological dysregulation
      • Structural and functional brain abnormalities
        • Not unique to schizophrenia
  • Psychological and Social Influences
  • Double bind hypothesis: when the parent presents child with ideas, demands, feelings that are mutually incompatible. E.g. a mother may scold his child for lack of affection but punish him for coming close. According to Bateson, such disorganised communications in the family may come to be reflected in the child’s thinking. No solid confirmation of this hypothesis however has been shown.
  • Communication deviance: is a measure of how understandable & easy to follow the speech of family members is. Wahlberg et al found that high risk children who were raised by adopted families low in communication deviance had healthier follow up than even low risk children raised by adopted families low in communication deviance. This, suggests that it is the combination of genetic risk & high communication deviance.
  • Expressed Emotion (Brown): is a measure of the family environment. It has 3 main elements:
    • Criticism: reflects dislike or disapproval of patient.
    • Hostility: indicates dislike or rejection of patient as a person.
    • emotional overinvolvement: dramatic or overconcerned attitude towards patient’s illness.
    • EE has been able to predict relapse in patients with schizophrenia. Butzlaff & Hooley, 1998 showed that living in high EE homes more than doubled baseline level of relapse risk for schizophrenia in 9-12 months after hospitalization. EE may play a causal role in the relapse process:
  • Diasthesis stress model: environmental stress (i.e. EE) is thought to interact with preexisting biological vulnerabilities to increase probability of relapse.
  • Stress response: 2 of the major neuotransmitters implicated in schizophrenia are affected by cortisol.
    • stress triggers    
    • cortisol triggers
    •  dopamine activity wich also affects glutamate release 
  • Sociogenic hypothesis & social drift theory: According to sociogenic hypothesis, Degrading treatment, low level of education & unavailability of rewards & opportunities may make membership to a low social class itself such a stressful experience that the individual develops schizophrenia. According to social drift theory, schizophrenics may drift into poverty ridden areas. The growing cognitive & motivational problems may impair their earning abilities & thus they cannot afford to live elsewhere.
  • Urban living:  being raised in an urban environment seems to increase a person’s risk of developing schizophrenia. Research of Pederson & Mortenson, 2001, found that children who spent their first 15 yrs living in urban environment were 2.7 times more likely to develop schizophrenia in adulthood than the children who spent their childhoods in more rural settings.
  • Immigration: Recent immigrants also have found to have higher risks for developing schizophrenia than people who are native to the country of immigration. Cantor-Grace et al, 2005, found that 1st generation immigrants had 2.7 times the risk of developing schizophrenia; for 2nd generation immigrants the risk was even higher at 4.5.One possibility for is that immigrants are more likely to receive this diagnosis due to cultural misunderstandings. Another possibility may be that healthy people who feel discriminated against are more likely to develop psychotic symptoms than those who do not.


  • Medical Treatment of Schizophrenia
    • Development of antipsychotic (neuroleptic) medications
      • Often the first line treatment for schizophrenia
      • Most reduce or eliminate positive symptoms
      • Primarily affect dopamine system, but also affect serotonergic and glutamate system
    • Acute and permanent side effects are common with first-generation medications
      • Parkinson’s-like side effects
      • Tardive dyskinesia
      • Compliance with medication is often a problem
        • Aversion to side effects
        • Financial cost
        • Poor relationship with doctors
  • Psychosocial Treatment of Schizophrenia
    • Psychodynamic therapy was not effective
    • Psychosocial approaches
      • Behavioral (i.e., token economies) on inpatient units: reward adaptive behavior
      • Community care programs
      • Social and living skills training
      • Behavioral family therapy
      • Vocational rehabilitation
    • Illness management and recovery
      • Engages patient as an active participant in care
      • Continuous goal setting and tracking
      • Modules include: social skills training, stress management, substance use
    • Cultural considerations
      • Take into account cultural factors that influence individuals’ understanding of their own illness (e.g., supernatural beliefs)
      • Involve family and community if possible
    • Prevention
      • Identify at-risk children
        • Relatives of individuals with schizophrenia
      • Foster supportive, stable environments
      • Offer additional treatment at prodromal stages, including social skills training

Sexual Dysfunctions, Paraphilic Disorders, and Gender Dysphoria

Male Hypoactive Sexual Desire Disorder

  • Little or no interest in any type of sexual activity
  • Masturbation, sexual fantasies, and intercourse are rare
  • Accounts for half of all complaints at sexuality clinics
  • Affects 5% of men

Erectile Disorder                 

  • Difficulty achieving or maintaining an erection even when presented with a sexually stimulating stimuli
  • Most common problem for which men seek treatment
  • Prevalence increases with age
    • 60% of men over 60 experience erectile dysfunction

Sexual Arousal Disorders

Female Sexual Interest/Arousal Disorder

  • Lack of or significantly reduced sexual interest/arousal
    • Typically manifesting in:
      • fewer sexual thoughts
      • reduced arousal to sexual cues
      • reduced pleasure or sensations during almost all sexual encounters
      • reduced sexual interest
      • reduced sexual activity

Female Orgasmic Disorder

  • Marked delay, absence or decreased intensity of orgasm in almost all sexual encounters
  • Not explained by relationship distress or other significant stressors
  • 1 in 4 women has significant difficulty achieving orgasm

Premature ejaculation

  • Ejaculation occurring within a  short period of intercourse, usually 1 minute of penetration
    • An important criteria is also that premature ejaculation must occur at a time that is before it is desired
  • Most prevalent sexual dysfunction in adult males
    • Affects 21% of all adult males
    • Most common in younger, inexperienced males
    • Problem tends to decline with age

Genito-Pelvic Pain/Penetration Disorder

  • In females, difficulty with vaginal penetration during intercourse, associated with one or more of the following:
    • Pain during intercourse or penetration attempts
    • Fear/anxiety about pain during sexual activity
    • Tensing of pelvic floor muscles in anticipation of sexual activity

Causes of Sexual Dysfunction

  • Psychological contributions
    • People experience anxiety and negative thoughts which could lead to sexual dysfunction
    • May actively avoid awareness of sexual cues in order to avoid anxiety that is associated
      • Example: Men with PE tend to distract themselves purposefully to avoid orgasm
  • Effect of anxiety on sexual arousal
    • Previously believed to decrease arousal and contribute to sexual dysfunction
    • But in some cases, anxiety (e.g., about getting an electric shock in the laboratory) increases arousal in response to erotic material
    • The optimum amount of anxiety is important, along with positive cognitive thoughts.
  • Distraction often increases arousal and awareness of own sexual response
  • Social and cultural contributions
    • Erotophobia: Associate sexuality with negative feelings, anxiety or threat
    • Unpleasant or traumatic sexual experiences

Treatment of Sexual Dysfunction

  • Psycho-Education alone can be surprisingly effective
    • Masters and Johnson’s psychosocial intervention
      • Education about sexual response, foreplay, etc.
      • Sensate focus and nondemand pleasuring
        • Sexual activity with the goal of focusing on sensations without trying to achieve orgasm
        • Decreases performance anxiety
    • Additional psychosocial procedures
      • Squeeze technique – premature ejaculation
      • Masturbatory training – female orgasm disorder
      • Use of dilators – vaginismus
      • Exposure to erotic material – low sexual desire problems
  • Medical Treatment of Sexual Dysfunction
    • Erectile dysfunction
      • Viagra
        • Headache side effects, many discontinue
      • Injection of vasodilating drugs into the penis
      • Testosterone
      • Penile prosthesis or implants
      • Vascular surgery
      • Vacuum device therapy
    • Few medical procedures exist for female sexual dysfunction

Paraphilic Disorders

  • Paraphilias or Perversions are deviations from normal sexual behaviours, but are necessary for some persons to experience arousal and orgasm.
    • Often are focused on inappropriate individuals or things
    • Often manifold paraphilic forms of arousal
    • High comorbidity with anxiety, mood, and substance use disorders
  • Manifest in fantasies, urges, arousal or behaviors
  • Paraphilias are notalways disordered
    • Only considered disordered when the individual experiences clinically significant distress or impairment or acts on urges with a nonconsenting person

Transvestic Fetishism Disorder

  • Sexual arousal by cross-dressing
  • Typically begins in childhood or early adolescence.
  • Although labelled as a disorder this is not inherently pathological. It is onlyconsidered as disordered if it causes significant distress or impairment

Pedophilic Disorder

  • Repeated intense sexual urges toward, or arousal by, children 13 years of age or younger, over a period of at least 6 months
    • Persons with pedophilia are at least 16 years of age and at least 5 years older than the victims
    • Vast majority of sufferers are males
      • Pedophilia is rare, but not unheard of, in females
    • In some cases, pedophilic urges are limited to incest (i.e., young members of one’s own family)
    • Many sufferers do notact on desire and engage in compensatory moral behavior

Frotteuristic Disorder

  • When a male seeks sexual gratification by rubbing up against unwilling others
  • The male may use his hands to rub an unsuspecting victim
    • This usually takes place in crowds and/or confining situations from which the other person cannot escape
      • Examples: Crowded elevator or subway

Fetishistic Disorder

  • Sexual focus is on objects that are intimately associated with the human body
  • Sexual activity may be directed toward the fetish itself (e.g., masturbation with or into a shoe), or the fetish may be incorporated into sexual intercourse
  • According to Freud, the fetish serves as a symbol of the phallus to persons with unconscious castration fears. Examples: May include rubber, hair, feet, objects such as shoes

Sexual sadism

  • Psychological or physical suffering (including humiliation) of the victim is sexually exciting to the person.

Sexual masochism

  • Suffering pain or humiliation by another person to attain sexual gratification
  • Sexual Sadism, Paraphilia and Rape
    • Sexual sadism is related to rape, although rape is more aptly considered an expression of power. Some sadistic rapists, however, kill their victims after having sex (so-called lust murders).
    • Most rapists do not show paraphilic patterns of arousal
    • Rapists tend to show sexual arousal to violent sexual and non-sexual material


  • Also known as scopophilia,
    • It is the recurrent preoccupation with fantasies and acts that involve observing persons who are naked or engaged in grooming or sexual activity.
    • Risk associated with “peeping” may intensify sexual arousal
      • The first voyeuristic act usually occurs during childhood


  • The urge to expose one’s genitals to unsuspecting strangers
    • Element of thrill and risk is necessary for sexual arousal

Causes of Paraphilic Disorders

  • Classic psychoanalytic model- failure to complete the normal developmental process toward heterosexual adjustment.
  • Failure to resolve the oedipal crisis by identifying with the father-aggressor (for boys) or mother-aggressor (for girls) results in improper choice of object for libido cathexis.
  • Difficulty forming “normal” relationships with some deficits in typical sexual experiences
    • A link has also been established with difficulties in childhood or adolescence
    • Early experiences may lead to sexual associations by chance > then reinforced through masturbation
  • Often have very high sex drive


Psychosocial Interventions for Paraphilic Disorders

  • Cognitive-behavioral therapy– is used to disrupt learned paraphiliac patterns and modify behavior to make it socially acceptable. The interventions include social skills training, sex education, cognitive restructuring (confronting and destroying the rationalizations used to support victimization of others), and development of victim empathy.
    • CBT: Target deviant and inappropriate sexual associations
    • Learning: Covert sensitization – imagining aversive consequences to form negative associations with deviant (e.g., pedophilic) behavior
      • Orgasmic reconditioning – masturbation to appropriate (adult) stimuli
    • Family/marital therapy – address any interpersonal and incest related problems
    • Efficacy is mixed
      • Poorest outcomes = Rapists and patients with multiple paraphilias
      • Outpatient treatment is more successful
  • Medications
    • Cyproterone acetate (“chemical castration”)
      • Reduces desire and fantasy dramatically, but they return after drug removal
    • Depo-Provera: reduces testosterone
    • Most useful for dangerous sexual offenders; some take the drug to avoid going to prison

Gender Dysphoria

  • Clinical overview – important to note the difference with gender non conformity. In gender dysphoria, there is the presence of clinically significant stress.
    • Feeling trapped in the body of the wrong sex
    • Often assuming identity of the desired sex
  • Causes are unclear
    • Gender identity usually begins between 18-36 months of age
    • Fluid or cross-gender identity is not a disorder unless it causes significant distress or impairment
      • Relatively rare
      • Female to Male ratio = 1:2.3 (i.e., more common in males)
    • Rates are similar across cultures
      • Some cultures revere individuals with nontraditional gender experience (e.g., biological male adopting a female role seen as a shaman) and therefore are not considered to be part of a disorder
    • No clear biological causes identified, but likely has genetic component
      • Studies have found that a high percentage of variance in gender expression is explained by genetics.
      • Exposure to certain hormones in the womb (e.g., higher levels of testosterone may masculinize a female fetus)

Treating Gender Dysphoria

  • Sex Reassignment Surgery
    • Must be psychologically/socially stable and live as desired gender for several years first
      • One-third of all individuals report satisfaction with new identity

Treatment of intersexuality

  • Often treated with surgery at birth
    • Gender dysphoria may occur later in life and needs to be addressed

Treatment of Gender Nonconformity in Children

  • Gender nonconformity is common and may not lead to gender dysphoria
    • Gender nonconformity can lead to negative social experiences
    • Conflict between affirming child’s identity and encouraging cis-gender behavior to improve social adjustment
    • Treatment should be individualized to specific child’s needs and environment

Personality Disorders

  • Personality Disorders
    • A persistent pattern of emotions,  cognitions and behavior that results in enduring emotional distress  for the person affected and/or for others and may cause difficulties with work and relationships
  • Personality Disorders: An Overview
    • Enduring and inflexible predispositions that are maladaptive, causing distress and/or impairment
    • High comorbidity with other disorders
    • Ego-syntonic: Unlike other disorders, often feel consistent with one’s identity; patients don’t feel that treatment is necessary
    • 10 specific personality disorders organized into 3 clusters
  • Personality Disorders: An Overview
  • DSM-5 personality disorder clusters
    • Cluster A – odd or eccentric cluster
    • Cluster B – dramatic, emotional, erratic cluster
    • Cluster C – fearful or anxious cluster
  • Prevalence of personality disorders
    • Affects about 1% of the general population
  • Origins and course of personality disorders
    • Tend to run a chronic course
      • May transition into a different personality disorder
  • Gender distribution and gender bias in diagnosis
    • Antisocial – more often male
    • Histrionic – more often female
  • Comorbidity is the rule, not the exception
    • Often have two or more personality disorders or an additional mood or anxiety disorder
  • DSM-5 Personality Disorders
  • Cluster A = Odd or Eccentric
    • Paranoid, schizoid and schizotypal personality disorders
  • Cluster B = Dramatic or Erratic
    • Antisocial, borderline, histrionic and narcissistic personality disorders
  • Cluster C = Anxious or Fearful
    • Avoidant, dependent and obsessive-compulsive personality disorders

Cluster A: Paranoid Personality Disorder

  • Clinical features
    • Pervasive and unfounded distrust and suspicion
    • No many relationships
      • Probably because they are sensitive to criticism
      • Lack of relationships also create poor quality of life
    • They refuse responsibility for their own feelings and assign responsibility to others.
    • Often hostile, irritable, and angry
  • Causes
    • Not well understood
    • May involve early learning that people and the world are dangerous or deceptive at an early age
    • Cultural factors: more often found in people with experiences that lead to mistrust of other
      • Prisoners
      • Refugees
      • People with hearing impairments
      • Older adults


  • Few seek professional help on their own
    • Treatment focuses on development of trust
    • Cognitive therapy to counter negativistic thinking

Cluster A: Schizoid Personality Disorder

  • Overview and clinical features
    • Pervasive pattern of disinterest from social relationships
    • Limited range of emotions in interpersonal situations
  • Causes
    • Unclear
    • Correlation with childhood shyness
      • Preference for social isolation resembles autism
    • Some individuals experienced abuse or neglect in childhood


  • Few seek professional help on their own
    • Focus on the value of interpersonal relationships
    • Building empathy and social skills

Cluster A: Schizotypal Personality Disorder

  • Overview and clinical features
    • Behavior and dressing is odd and unusual
    • Usually also socially isolated and highly suspicious but not always
    • Magical thinking, ideas of reference, and illusions
  • Causes
    • Unclear
    • May be more likely to develop after childhood maltreatment or trauma, especially in men


  • Main focus is on developing social skills
    • Medical treatment is similar to that used for schizophrenia
    • Treatment prognosis is generally poor

Cluster B: Antisocial Personality Disorder

  • Overview and clinical features
    • Failure to comply with social norms
    • Violation of the rights of others
    • Irresponsible, impulsive, and deceitful
    • Lack of a conscience, empathy, and remorse
    • “Sociopathy,” “psychopathy” typically refer to this disorder or very similar traits
    • May be very charming, interpersonally manipulative
    • Criminality in Antisocial Psychopaths
    • Often show early histories of behavioral problems, including conduct disorder
    • “Callous-unemotional” type of conduct disorder more likely to evolve into antisocial PD
  • Causes
    • Families with inconsistent parental discipline and support
    • Families often have histories of criminal and violent behavior
    • Neurobiological Contributions:
      • Underarousal hypothesis – cortical arousal is too low and therefore require high arousal and gain that through non-conforming behaviour
      • Cortical immaturity hypothesis – cerebral cortex is not fully developed leading to impulse control issues
      • Fearlessness hypothesis – fail to respond to danger cues due to less anxiety response and poor conditioning of fear
      • Gray’s model: Inhibition signals are outweighed by reward signals
    • Genetic influences
      • More likely to develop antisocial behavior if parents have a history of antisocial behavior or criminality
    • Developmental influences
      • High-conflict childhood increases likelihood of APD in at-risk children
    • Mutual biological-environmental influence
      • Early antisocial behavior alienates peers who would otherwise serve as corrective role models
      • Antisocial behavior and family stress mutually increase one another

Treatment of Antisocial Personality

  • Few seek treatment on their own
    • Emphasis is placed on prevention and rehabilitation
    • Often imprisonment is the only viable alternative
    • May need to focus on practical (or selfish) consequences (e.g., if you assault someone you’ll go to prison)
    • Poor prognosis

Cluster B: Borderline Personality Disorder

  • Overview and clinical features
    • Unstable moods and relationships
    • Impulsivity, fear of abandonment, very poor self-image
    • Self-mutilation and suicidal gestures
  • Causes
    • Strong genetic component
    • High emotional reactivity may be inherited
    • Linbic system may be impaired in functioning
    • Early trauma/abuse increase risk
    • Many BPD patients have high levels of shame and low self esteem
    •  “Triple vulnerability” model of anxiety applies borderline personality too
    • Results form the combination of:
      • generalized biological vulnerability (reactivity)
      • generalized psychological vulnerability (lash out when threatened)
      • specific psychological vulnerability (stressors that elicit borderline behavior)


  • Antidepressant medications provide some short-term relief
    • Dialectical behavior therapy is most promising treatment

Cluster B: Histrionic Personality Disorder

  • Overview and clinical features
    • Overly dramatic and sensational.  They may be sexually provocative and impulsive, craving the center of attention
    • Thinking and emotions are perceived as shallow
    • More commonly diagnosed in females


  • Etiology unknown due to lack of research
    • Often co-occurs with antisocial PD


  • Focus on attention seeking and long-term negative consequences
    • Targets may also include problematic interpersonal behaviors
    • Little evidence that treatment is effective

Cluster B: Narcissistic Personality Disorder

  • Overview and clinical features
    • Exaggerated and unreasonable sense of self-importance
    • Preoccupation with receiving attention
    • Lack sensitivity and compassion for other people
    • Highly sensitive to criticism; envious, and arrogant

Causes are largely unknown

  • Failure to learn empathy as a child
    • Sociological view – product of the “me” generation


  • Focus on grandiosity, lack of empathy, unrealistic thinking
    • Emphasize realistic goals and coping skills for dealing with criticism
    • Little evidence that treatment is effective

Cluster C: Avoidant Personality Disorder

  • Overview and clinical features
    • Highly avoidant of most interpersonal relationships
    • Interpersonally anxious and fearful of rejection
    • Low self esteem


  • Occurs more often in relatives of people with schizophrenia
    • Experiences of early rejection may also be linked


  • Similar to treatment for social phobia
    • Focus on social skills, entering anxiety-provoking situations
    • Good relationship with therapist is important

Cluster C: Dependent Personality Disorder

  • Overview and clinical features
    • Reliance on others to make major and minor life decisions
    • Unreasonable fear of abandonment
    • Clingy and submissive in interpersonal relationships


  • Not well understood due to lack of research
    • Linked to early disruptions in learning independence


  • Research on treatment efficacy is lacking
    • Therapy typically progresses gradually due to lack of independence
    • Treatment targets include skills that foster confidence and independence

Cluster C: Obsessive-Compulsive Personality Disorder

  • Overview and clinical features
    • Rigid fixation on doing things the right way and Highly perfectionistic, orderly, and emotionally shallow
    • Unwilling to delegate tasks because others will do them wrong
    • Difficulty with spontaneity
  • Causes are not well known
    • Weak genetic contribution


  • Little data on treatment
    • Address fears related to the need for orderliness
    • Target rumination, procrastination, and feelings of inadequacy

Neurocognitive Disorders

  • Types of neurocognitive disorders
    • Delirium – temporary confusion and disorientation
    • Major or mild neurocognitive disorder – broad cognitive deterioration affecting multiple domains
    • Amnestic – refers to problems with memory that may occur in neurocognitive disorders
  • Neurocognitive Disorders
    • Shifting DSM perspectives
      • From “organic” mental disorders to “cognitive” disorders
      • Broad impairments in cognitive functioning
      • Cause profound changes in behavior and personality
        • Thus, although some may consider these to be general medical conditions, often best treated by mental health professionals


  • Acute decline in both the level of consciousness and cognition with particular impairment in attention.
  • Nature of delirium
    • Central features – impaired consciousness and cognition
    • Develops rapidly over several hours or days
    • Appear confused, disoriented, and inattentive
    • Marked memory and language deficits
    • More prevalent in certain populations, including:
      • Older adults
      • Those undergoing medical procedures
      • AIDS patients and cancer patients
    • Full recovery often occurs within several weeks
  • Medical Conditions Related to Delirium
    • Medical conditions
      • Infections
      • Drug intoxication, poisons, withdrawal from drugs
      • Head injury and several forms of brain trauma
      • Sleep deprivation, immobility, and excessive stress
      • Dementia (50% of cases involve temporary delirium)


  • Psychosocial interventions
    • Family support
    • Change in environment
    • Reassurance/comfort, coping strategies, inclusion of patients in treatment decisions
  • Prevention
    • Address proper medical care for illnesses, proper use and adherence to therapeutic drugs


  • A syndrome that is chronic and progressive in nature
  • Affects higher cognitive functions
  • Consciousness not clouded
  • Deterioration in emotional control, social behavior, motivatio
    • Deterioration in language / advanced cognitive processes
    • Has many causes and may be irreversible 
  • Cognitive impairments:
    • Memory:
      • Forgetting recent events and conversations, repetitive questions, repetitive retelling of stories, forgetting the date, forgetting appointments, misplacing objects, losing valuables
      • Inability to learn new information
      • Procedural memory relatively intact in the beginning
    • Aphasias:
      • Word finding difficulties, word substitutions, mispronunciations
      • Apraxias: Difficulty in motor control
      • Agnosias: Inability to recognize
      • Impairment in executive functions
    • Functional Impairment
      • Behavioral Disturbances: disinhibition, agitation, aggressive behaviour, uncooperative behaviour, and wandering
      • Mood Changes
      • Anxiety
      • Personality changes
      • Psychosis
      • Sleep disturbances
      • Consciousness remains intact

Mild neurocognitive disorder: New DSM-5 classification for early stages of cognitive decline

  • Individual is able to function independently with some accommodations (e.g., reminders/lists)

Major Neurocognitive Disorder (New name for Dementia)

  • DSM-5 criteria
    • One or more cognitive deficits that represent a decrease from previous functioning
    • Substantiated by clinical assessment
    • Interfere with daily independent activities
    • New case identified every 7 seconds
    • 5% prevalence in adults 65+; 20% prevalence in adults 85+
    • Prevalence of mild neurocognitive disorder is greater: 10% of adults 70+
  • Initial stages
    • Memory and visuospatial skills impairments
    • Facial agnosia – inability to recognize familiar faces
    • Other symptoms
      • Delusions, apathy, depression, agitation, aggression
  • Later stages
    • Cognitive functioning continues to deteriorate
    • Total support is needed to carry out day-to-day activities
    • Increased risk for early death due to inactivity and onset of other illnesses
  • DSM-5 Types of Major and Mild Neurocognitive Disorder
    • Due to Alzheimers Disease
    • Frontotemporal
    • Vascular
    • With Lewy bodies
    • Due to traumatic brain injury
    • Substance/medication induced
    • Due to HIV infection
    • Due to prion disease
    • Due to Parkinson’s Disease

Neurocognitive Disorder Due to Alzheimer’s Disease

  • Accounts for nearly half of neurocognitive disorders
    • Clinical Features
      • Typically develop gradually and steadily
      • Memory, orientation, judgment, and reasoning deficits
      • Additional symptoms may include
        • Agitation, confusion, or combativeness
        • Depression and/or anxiety
  • Nature and progression of the disease
    • “Nun study” – analysis of nuns’ journal writing over many years shows patterns of deterioration 
      • Early and later stages = slow
      • During middle stages = rapid
    • Post-diagnosis survival = 8 years
    • Onset = 60s or 70s (“early onset” = 40s to 50s)
  • 50% of the cases of neurocognitive disorder result from Alzheimer’s disease
    • More common in less educated individuals
      • More educated individuals decline more rapidly after onset; this suggests that education simply provides a buffer period of better initial coping
    • Slightly more common in women
      • Possibly because women lose estrogen as they age; estrogen may be protective
  • Range of cognitive deficits
    • Aphasia – difficulty with language
    • Apraxia – impaired motor functioning
    • Agnosia – failure to recognize objects
    • Difficulties with
      • Planning, Organizing
      • Sequencing
      • Abstracting information
    • Negative impact on social and occupational functioning

Vascular Neurocognitive Disorder

  • Caused by blockage or damage to blood vessels
  • Onset is sudden (e.g., stroke)
  • Formal care is required in later stages
  • Features
    • Cognitive disturbances – identical to dementia
    • Obvious neurological signs of brain tissue damage
    • Risk slightly higher in men

Frontotemporal Neurocognitive Disorder

  • Broadly refers to damage to the frontal or temporal regions of the brain, affecting
    • Personality
    • Language
    • Behavior
  • Two types of impairment
    • Declines in appropriate behavior
    • Declines in language
  • Example: Pick’s disease
    • Neurocognitive Disorder Due to Pick’s Disease
      • Rare neurological condition which accounts for 5% of all dementia diagnoses
      • Produces a cortical dementia like Alzheimer’s
    • Occurs relatively early in life (around 40s or 50s)
    • Little is known about what causes this disease

Neurocognitive Disorder Due to Traumatic Brain injury

  • Accidents are leading cause
  • Symptoms last for at least one week after head injury, including problems with executive function, learning, memory
    • Memory loss is the most common symptom
  • May be found in athletes who experience repeated blows to the head (e.g., football players)

Neurocognitive Disorder Due to Lewy Body Disease

  • Lewy bodies = microscopic protein deposits that damage brain over time
  • Symptoms onset gradually
  • Symptoms include impaired attention and alertness, visual hallucinations, motor impairment

Neurocognitive Disorder Due to Parkinson’s Disease

  • Parkinson’s disease is characterized by motor symptoms such as resting tremors or rigid movements
    • Loss of dopamine neurons in an area of the brain called the substantia nigra.
    • Movements not  in a controlled and fluid manner
    • Psychological and cognitive symptoms
    • 25-40% develop dementia
    • 75% survive 10+ years after diagnosis

Neurocognitive Disorder due to HIV Infection

  • HIV-1 can cause neurological impairments and dementia in some individuals
    • Cognitive slowness, impaired attention, and forgetfulness
    • Apathy and social withdrawal
    • Typically occurs in later disease stages
    • Now occurs in <10% of individuals with HIV; HAART decreases risk

Neurocognitive Disorder Due to Huntington’s Disease

  • Chronic, progressive chorea (involuntary and irregular movements that flow randomly from one area of the body to another).
  • Huntington’s disease is caused by a single dominant gene on chromosome 4.
  • Patients eventually develop dementia

Neurocognitive Disorder Due to Prion Disease

  • Disorder of proteins in the brain that reproduce and cause damage
  • Fatal without treatment
  • Can only be acquired through cannibalism or accidental transmission (e.g., contaminated blood transfusion)

Substance/Medication-Induced Neurocognitive Disorder

  • Results from prolonged drug use, especially in combination with poor diet
  • May be caused by alcohol, sedative, hypnotic, anxiolytic or inhalant drugs
  • Brain damage may be permanent
  • Symptoms similar to Alzheimer’s
  • Deficits may include
    • Memory impairment
    • Aphasia, apraxia, agnosia
    • Disturbed executive functioning
    • Causes of Neurocognitive Disorder:
      The Example of Alzheimer’s Disease

Features of brains with Alzheimer’s disease

  • Amyloid plaques: Accumulation of a protieb beta amyloid
  • Neurofibrillary tangles:  Webs of abnormal filaments within a nerve cell made up of a protein called tau.
  • Atrophy (shrinkage) of the brain

Causes of Neurocognitive Disorder: The Example of Alzheimer’s Disease

  • Genes on chromosomes 21, 19, 14, 12 are implicated
  • Chromosome 19 is associated with late onset Alzheimer’s
  • Chromosome 14 is associated  with early onset Alzheimer’s
  • Rare genes that inevitably lead to Alzheimer’s
    • Beta-amyloid precursor gene
    • Presenilin-1 and Presenilin-2 genes
  • Susceptibility genes
    • Make it more likely but not certain to develop Alzheimer’s
    • Example of susceptibility gene: ApoE4 gene
      • Located on chromosome 19
      • Associated with late onset Alzheimer’s
      • Among Alzheimer’s patients, more prevalent in those who also have a family history of the disease
      • More likely to produce cognitive decline in the context of a stressful environment (gene-environment interaction)
  • Psychosocial factors: do not cause dementia directly
    • May influence onset and course
      • Lifestyle factors – drug use, diet, exercise, stress
      • Educational attainment, coping skills, social support


  • Most treatments attempt to slow progression of deterioration, but cannot stop it
  • Some drugs target cognitive deficits
    • Cholinesterase-inhibitors: Aricept, Exelon, Reminyl
    • Long-term effects not well demonstrated
  • SSRIs for depression and anxiety
  • Antipsychotics for agitation
    • All are only modestly effective for short periods
  • Psychosocial Treatment of Neurocognitive Disorders
    • Aims of psychosocial treatments
      • Improve lives of patients and their families
      • Communicate compensatory aids
      • Use memory enhancement devices
        • Example: Mnemonics for family members names
      • Cognitive stimulation can delay onset of more severe symptoms
  • Caregivers get instructions on how to handle problematic behavior such as wandering, aggressive behaviour, and socially inappropriate behaviour
  • Caregivers are asked to undergo therapy themselves due to the amount of stress
  • Prevention of Neurocognitive Disorders
    • Reducing risk in older adults
      • Use of anti-inflammatory medications
      • Control blood pressure, don’t smoke and lead active social life
    • Other targets of prevention efforts
      • Increasing safety behaviors to reduce head trauma
      • Reducing exposure to neurotoxins and use of drugs

Substance-Related and Addictive Disorders

  • Substance use refers to intake of moderate amounts of a substance which doesn’t day-to-day functioning
  •  Substance intoxication refers to physiological reaction (high/perceptual changes) to the consumption of a substance (e.g., being drunk)
  • Substance abuse refers to the intake of a substance in a way that is dangerous or causes substantial impairment in many areas of functioning (e.g., affecting job or relationships)
  • Substance dependence is defined in two manners:
    • Increase in tolerance followed by withdrawal
    • Or drug-seeking behavior (e.g., spending too much money on substance)
  • Tolerance is defined as the need of more of a substance to continue to feel the same effect as was previously felt with less amounts of that substance.
  • Withdrawal refers to negative/unwanted physiological reactions to the absence of substance or discontinuation after regular use.
  • Five Main Categories of Substances
    • Depressants- Behavioral sedation (e.g., alcohol, sedative, anxiolytic drugs)
    • Stimulants- Increase alertness and elevate mood (e.g., cocaine, nicotine)
    • Opiates- Produce analgesia and euphoria (e.g., heroin, morphine, codeine)
    • Hallucinogens- Alter sensory perception (e.g., marijuana, LSD)
    • Other drugs of abuse- Include inhalants, anabolic steroids, medications

Substance Use Disorders in DSM-5


  • Pattern of substance use leading to significant impairment and distress
  • Symptoms (need 2+ within a year)
    • Taking more of the substance than intended
    • Desire to cut down use
    • Excessive time spent using/acquiring/recovering
    • Craving for the substance
    • Role disruption (e.g. can’t perform at work)
    • Interpersonal problems
    • Pattern of substance use leading to significant impairment and distress
    • Reduction of important activities
    • Use in physically hazardous situations (e.g. driving)
    • Keep using despite causing physical or psychological problems
    • Tolerance
    • Withdrawal
  • DSM-5 now spells out criteria for:
    • Substance intoxication for different types of substances (e.g., alcohol, stimulants)
    • Substance use disorders for different types of substances
    • Withdrawal from different types of substances

The Depressants:

Alcohol-Related Disorders 


  • Psychological and physiological effects of alcohol are on:
    • Central nervous system
      • Influences several neurotransmitter systems
      • GABA
        • Increases inhibitory effects – slows down the firing of neural cells
    • Leads to Intoxication, followed by Withdrawal 
      • Delirium tremens – hallucinations and tremors brought on by withdrawal from severe alcohol use
      • Alcohol withdrawal, even without delirium, can be serious; it can include seizures and autonomic hyperactivity. Conditions that may predispose to, or aggravate, withdrawal symptoms include fatigue, malnutrition, physical illness, and depression.
    • Fetal alcohol syndrome – problems in fetus from alcohol use during pregnancy
      • Leads to impaired growth, cognitive difficulties, and behavioral problems in the child
    • Long term heavy alcohol use may lead to:
      • Dementia 
      • Wernicke-Korsakoff disorder- the individual feels confusion, lack of coordination and impaired speech.
      • Inability in learning new information, inability to remember recent events and long-term memory gaps
    • Progression of Alcohol Related Disorders
      • 20% are able to stop drinking on their own
      • Dependence usually develops over time, but course may be variable.
      • Individuals for whom alcohol is lesssedating are more likely to become dependent
    • Alcohol and violence
      • Drinking does not cause violence, but may increase the likelihood of impulsive behaviour

Sedative, Hypnotic, or Anxiolytic-Related Disorders


  • The nature of drugs in this class
    • Sedatives – usually related to relaxing or calming (e.g., barbiturates)
    • Hypnotic – usually related to sleep inducing
    • Anxiolytic – usually related to anxiety reduction (e.g., benzodiazepines)
      • Have generally tranquilizing effects
      • Usually act on GABA receptors
      • Effects are similar to large doses of alcohol
        • Combining such drugs with alcohol is dangerous

DSM-5 criteria for this class of disorders

  • The continued use of these drugs leads to increase in tolerance which would inevitably cause significant interference or distress



  • Main work is to increase alertness and increase energy (e.g. include amphetamines, cocaine, nicotine, and caffeine
  • DSM-5 criteria for stimulant intoxication: significant impairment or psychological changes
    • Accompanied by physical changes (e.g., change in HR/BP, dilated pupils, weight loss, vomiting, weakness, chills)
    • Effects of amphetamines
      • Produce elation, vigor, reduce fatigue
      • Such effects are usually followed by extreme fatigue and depression
    • Amphetamines stimulate CNS by
      • Enhancing release of norepinephrine and dopamine
      • Reuptake is subsequently blocked

Amphetamine Use Disorders

  • Some ADHD drugs are mild stimulants. E.g., Adderall, Ritalin
  • Ecstasy (MDMA) – Amphetamine effects, but without the crash
  • Crystal meth – Purified form of amphetamine
    • May cause aggressive tendencies in addition to high
    • Extreme risk of dependence

Cocaine-Related Disorders

  • Effects of cocaine
    • pupillary dilation
    • elevated or lowered blood pressure
    • perspiration or chills
    • nausea or vomiting
    • evidence of weight loss
    • psychomotor agitation or retardation
    • muscular weakness, respiratory depression, chest pain, or cardiac arrhythmias
    • confusion, seizures, dyskinesias, dystonias, or coma
    • Short lived sensations of elation, vigor, reduce fatigue
    • Nasal congestion;
  • Serious inflammation, swelling, bleeding, and ulceration of the nasal mucosa
  • Long-term use of cocaine can also lead to
    • perforation of the nasal septa
    • Effects result from blocking the reuptake of dopamine
    • Highly addictive, but addiction develops slowly
    • 1.9 million report use in US each year
  • Most cycle through patterns of tolerance and withdrawal
    • Withdrawal characterized by
      • Apathy
      •  boredom
      • fatigue
      • vivid, unpleasant dreams
      • insomnia or hypersomnia
      • increased appetite
      • psychomotor retardation or agitation
    • All of them lead to desire to use again
    • Cerebrovascular Effects
  • Nonhemorrhagic cerebral infarctions.
    • When hemorrhagic infarctions do occur, they can include
    • subarachnoid, intraparenchymal, and intraventricular hemorrhages.
  • Transient ischemic attacks have also been associated with cocaine use.
  • Seizures
    • Seizures have been reported to account for 3 to 8 percent of cocaine-related emergency room visits.
  • Cardiac Effects
    • Myocardial infarctions and arrhythmias are perhaps the most common cocaine-induced cardiac abnormalities.
    • Cardiomyopathies can develop with long-term use of cocaine, and cardioembolic cerebral infarctions can be a further complication of cocaine-induced myocardial dysfunction.
  • Death
    • High doses of cocaine are associated with seizures, respiratory depression, cerebrovascular diseases, and myocardial infarctions all of which can lead to death in persons who use cocaine.

Nicotine-Related Disorders

  • Nicotine is one of the most highly addictive and heavily used drugs in the United States and around the world. It causes lung cancer, emphysema, and cardiovascular disease and secondhand smoke is associated with lung cancer in adults and respiratory illness in children.
  • Effects of nicotine
  • Death is the primary adverse effect of cigarette smoking.
  • The causes of death include
    • chronic bronchitis and emphysema (51,000 deaths),
    • bronchogenic cancer (106,000 deaths),
    • 35 percent of fatal myocardial infarctions (115,000 deaths),
    • cerebrovascular disease,
    • cardiovascular disease, and
    • almost all cases of chronic obstructive pulmonary disease and
    • lung cancer
  • Smoking (mainly cigarette smoking) causes
    • cancer of the
      •  lung,
      • upper respiratory tract,
      • esophagus,
      • bladder, and
      • pancreas and
      • probably of the stomach, liver, and kidney.
    • Results in sensations of relaxation, wellness, pleasure
  • Nicotine users dose themselves to maintain a steady state of nicotine
  • Smoking has complex relationship to negative affect
    • Appears to help improve mood in short-term
    • Depression occurs more in those with nicotine dependence

Tobacco-Related Disorders


  • Criteria for Tobacco Withdrawal
  • After several weeks of daily use, unpleasant symptoms upon stopping or reducing:
    • An intense craving for nicotine,
    • Tension,
    • Irritability,
    • Difficulty concentrating,
    • Drowsiness and
    • Paradoxical trouble sleeping,
    • Decreased heart rate and blood pressure,
    • Increased appetite and weight gain,
    • Decreased motor performance, and
    • Increased muscle tension.
    • A mild syndrome of nicotine withdrawal can appear when a smoker switches from regular to low-nicotine cigarettes.
    • Insomnia,
    • Anxiety and depression
  • Symptoms lead to clinically significant distress or impairment

Caffeine-Related Disorders

Caffeine is the most widely consumed psychoactive substance in the world. Although numerous studies have documented the safety of caffeine when used in typical daily doses, psychiatric symptoms and disorders can be associated with its use.


  • Effects of caffeine – the “gentle” stimulant
    • Single low to moderate doses of caffeine (i.e., 20 to 200 mg) can produce a profile of subjective effects in humans that is generally identified as pleasurable.
    • Studies have shown that such doses of caffeine result in increased ratings on measures such as well-being, energy and concentration, and motivation to work.
    • Found in tea, coffee, cola drinks, and cocoa products
    • Small doses elevate mood and reduce fatigue
    • Regular use can result in tolerance and dependence
    • Caffeine blocks the reuptake of the neurotransmitter adenosine


  • Opioid abuse is a term used to designate a pattern of maladaptive use of an opioid drug leading to clinically significant impairment or distress


  • The nature of opiates and opioids
    • Opiate – natural chemical in the opium poppy with narcotic effects
    • Opioids – natural and synthetic substances with narcotic effects
    • Often referred to as analgesics
      • Analgesic = painkiller
  • Effects of opioids
    • Activate body’s enkephalins and endorphins
    • Low doses induce euphoria, drowsiness, and slowed breathing
    • High doses can result in death
    • Tolerance does not develop uniformly to all actions of opioid drugs.
    • Tolerance to some actions of opioids can be so high that a hundredfold increase in dose is required to produce the original effect.
    • The long-term use of opioids results in changes in the number and sensitivity of opioid receptors, which mediate at least some of the effects of tolerance and withdrawal.
    • Withdrawal symptoms can be lasting and severe
    • Mortality rates are high for opioid addicts
    • High risk for HIV infection due to shared needles

Cannabis-Related Disorders


  • Marijuana
    • Dilation of the conjunctival blood vessels (red eye) and
    • Mild tachycardia.
    • At high doses, orthostatic hypotension may appear.
    • Increased appetite often referred to as the munchies and dry mouth is common effects of cannabis intoxication.
    • Considered a mild hallucinogen
    • Most frequently used illegal drug
    • Active ingredient: Tetrahydrocannabinol (THC)
    • Variable, individual reactions
      • May include euphoria, mood swings, paranoia, hallucinations, reduced concentration
    • Dependence and withdrawal are uncommon
    • Long-term cannabis use is associated with cerebral atrophy, seizure susceptibility, chromosomal damage, birth defects, impaired immune reactivity, alterations in testosterone concentrations, and deregulation of menstrual cycles

Hallucinogen-Related Disorders


  • Hallucinations = altered sensory perceptions (e.g., seeing or hearing things that are not present)
  • pupillary dilation
  • tachycardia
  • sweating
  • palpitations
  • blurring of vision
  • tremors
  • incoordination
  • Hallucinogens can also produce delusions, paranoia
  • Examples of hallucinogens: LSD (most common), psilocybin, mescaline, PCP
  • Tolerance builds quickly, but resets after brief periods of abstinence

Other Drugs of Abuse: Inhalants

  • Found in volatile solvents
  • Breathed into the lungs directly
    • Rapid absorption
    • Examples: spray paint, hair spray, paint thinner, gasoline, nitrous oxide
  • Effects similar to alcohol intoxication
    • apathy,
    • diminished social and
    • occupational functioning,
    • impaired judgment, and
    • impulsive or aggressive behavior, and it can be accompanied by
    • nausea,
    • anorexia,
    • nystagmus,
    • depressed reflexes, and
    • diplopia
    • incoordination
    • slurred speech
    • unsteady gait
    • lethargy
    • depressed reflexes
    • psychomotor retardation
    • tremor
    • generalized muscle weakness
    • blurred vision or diplopia
    • stupor or coma
    • euphoria
  • Produce tolerance and prolonged withdrawal symptoms
  • Several negative physiological effects (e.g., organ damage)
  • Anabolic–Androgenic Steroids
  • Derived or synthesized from testosterone
  • Used medicinally or to increase body mass
  • No associated high
  • Rather, dependence involves wanting to maintain the effects of the substance (i.e., increased muscle mass)
  • May cause long-term mood disturbances

Causes of Substance-Related Disorders:

  1. Psychodynamic Factors
  2. According to classic theories, substance abuse is a masturbatory equivalent (some heroin users describe the initial rush as similar to a prolonged sexual orgasm), a defense against anxious impulses, or a manifestation of oral regression (i.e., dependency).
  • Recent psychodynamic formulations relate substance use as a reflection of disturbed ego functions (i.e., the inability to deal with reality).
  • As a form of self-medication, alcohol may be used to control panic, opioids to diminish anger, and amphetamines to alleviate depression.
  • Some addicts have great difficulty recognizing their inner emotional states, a condition called alexithymia (i.e., being unable to find words to describe their feelings).
  • Learning and Conditioning
  • Drug use, whether occasional or compulsive, can be viewed as behavior maintained by its consequences.
  • Drugs can reinforce antecedent behaviors by terminating some noxious or aversive state such as pain, anxiety, or depression.
  • In some social situations, the drug use, apart from its pharmacological effects, can be reinforcing if it results in special status or the approval of friends.
  • Each use of the drug evokes rapid positive reinforcement, either as a result of the rush (the drug-induced euphoria), alleviation of disturbed affects, alleviation of withdrawal symptoms, or any combination of these effects.
  • In addition, some drugs may sensitize neural systems to the reinforcing effects of the drug.
  • Eventually, the paraphernalia (needles, bottles, cigarette packs) and behaviors associated with substance use can become secondary reinforcers, as well as cues signaling availability of the substance, and in their presence, craving or a desire to experience the effects increases.
  • Drug users respond to the drug-related stimuli with increased activity in limbic regions, including the amygdala and the anterior cingulate (Cocaine, opioids, and cigarettes (nicotine)).
  • Other learning mechanisms probably play a role in dependence and relapse – Opioid and alcohol withdrawal phenomena can be conditioned (in the Pavlovian or classic sense) to environmental or interoceptive stimuli.
  • For a long time after withdrawal (from opioids, nicotine, or alcohol), the addict exposed to environmental stimuli previously linked with substance use or withdrawal may experience conditioned withdrawal, conditioned craving, or both.
  • The most intense craving is elicited by conditions associated with the availability or use of the substance, such as watching someone else use heroin or light a cigarette or being offered some drug by a friend.
  • Those learning and conditioning phenomena can be superimposed on any preexisting psychopathology, but preexisting difficulties are not required for the development of powerfully reinforced substance-seeking behavior.
  • Genetic Factors
  • Strong evidence from studies of twins, adoptees, and siblings brought up separately indicates that the cause of alcohol abuse has a genetic component.
  • Many less conclusive data show that other types of substance abuse or substance dependence have a genetic pattern in their development.
  • Researchers recently have used restriction fragment length polymorphism (RFLP) in the study of substance abuse and substance dependence, and associations to genes that affect dopamine production have been postulated.
  • Neurochemical Factors
  1. Receptors and Receptor Systems
  • With the exception of alcohol, researchers have identified particular neurotransmitters or neurotransmitter receptors involved with most substances of abuse.
  • Some researchers base their studies on such hypotheses. The opioids, for example, act on opioid receptors. A person with too little endogenous opioid activity (e.g., low concentrations of endorphins) or with too much activity of an endogenous opioid antagonist may be at risk for developing opioid dependence.
  • Even in a person with completely normal endogenous receptor function and neurotransmitter concentration, the long-term use of a particular substance of abuse may eventually modulate receptor systems in the brain so that the presence of the exogenous substance is needed to maintain homeostasis.
  • Such a receptor-level process may be the mechanism for developing tolerance within the CNS.
  1. Pathways and Neurotransmitters
  • The major neurotransmitters possibly involved in developing substance abuse and substance dependence are the opioid, catecholamine (particularly dopamine), and γ-aminobutyric acid (GABA) systems.
  • The dopaminergic neurons in the ventral tegmental area are particularly important.
  • These neurons project to the cortical and limbic regions, especially the nucleus accumbens.
  • This pathway is probably involved in the sensation of reward and may be the major mediator of the effects of such substances as amphetamine and cocaine.
  • The locus ceruleus, the largest group of adrenergic neurons, probably mediates the effects of the opiates and the opioids. These pathways have collectively been called the brain-reward circuitry.


  • Biological Treatment of Substance-Related Disorders
    • Agonist substitution
      • Safe drug with a similar chemical composition as the abused drug
    • Antagonistic treatment
      • Drugs that block or counteract the positive effects of substances
    • Aversive treatment
      • Drugs that make use of substances extremely unpleasant
    • Efficacy of biological treatment
      • Generally ineffective when used alone
      • Used to help with withdrawal symptoms
  • Psychosocial Treatment of Substance-Related Disorders
    • Community support programs
      • Alcoholics Anonymous (AA) and related groups (e.g., NA) may be helpful
    • Component treatment
      • Incorporate several elements such as psychotherapy and contingency management
    • Comprehensive treatment and prevention programs
      • Individual and group therapy
      • Aversion therapy and convert sensitization
      • Contingency management
      • Community reinforcement
      • Relapse prevention
    • Preventative efforts
      • Recent shift away from education approaches
      • Greater enforcement of anti-drug laws
      • Example: The 12 Steps of Alcoholics Anonymous
      • Relapse Prevention for Substance-Related Disorders
  • Cognitive-behavioral approach to learn habits that make relapse less likely
    • Address distorted cognitions
    • Identify negative consequences
    • Increase motivation to change
    • Identify high risk situations
    • Reframe relapse
      • Failure of coping skills, not person

Gambling Disorder

  • New disorder in DSM-5
  • Classified under “Addictive Disorders”
  • Recurrent gambling leading to clinically significant distress or impairment
  • Criteria
  • Associated with 4+ symptoms within a year:
    • Difficulty stopping/reducing gambling
    • restlessness/irritability when trying to cut back
    • need to gamble with increasing amounts of money
    • frequent preoccupation
    • gambling when distressed
    • attempting to “win it back” after a loss
    • lying about gambling
    • relying on others for financial support
    • jeopardizing a significant relationship/job/opportunity


  • Psychosocial treatment similar to substance abuse
    • Treatment is often ineffective
  • Motivation to get better is critical; dropout is high
    • Research is limited, but multipart CBT interventions are under investigation
    • Scheduling alternative activities, setting financial limits, relapse prevention

Impulse-Control Disorders

  • Each is characterized by:
    • Impairment of social and occupational functioning
    • May also involve increased tension/anxiety prior to the act, pleasurable anticipation, or a sense of relief following the act
  • Include:
    • Intermittent explosive disorder
    • Kleptomania
    • Pyromania
    • Impulse-Control Disorders
  • Intermittent explosive disorder
    • Rare condition
    • Characterized by frequent aggressive outbursts
    • Leads to injury and/or destruction of property
    • Few controlled treatment studies


  • Failure to resist urge to steal unnecessary items
    • Seems rare, but it is not well studied
    • Highly comorbid with mood disorders
    • Also co-occurs with substance-related problems


  • Involves having an irresistible urge to set fires
    • Diagnosed in just 3% of arsonists
    • Little etiological and treatment research
    • Treatment usually focuses on identifying urges and practicing incompatible behaviors.

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