Introduction to Depressive Disorders

What classifies a disorder as Depressive?

Each disorder within this class involves the individual feeling empty, sad and/or irritable, while also experiencing physical and cognitive changes that disrupt their typical functioning in school, at work, or in other important settings.  Depressive Disorders are distinguished from one another based on the timing, or age of onset of the symptoms; the duration of the symptoms; and, the presumed cause of the symptoms.

Prior to the publishing of the Diagnostic and Statistical Manual-5 (DSM-5), Depressive Disorders and Bipolar Related Disorders were within the same class.  These disorders were separated because depression is unipolar, meaning the diagnosed individual only experiences a “down” period; this is opposed to bipolar, where the diagnosed individual experiences both “up” and “down” periods.

Names of the Disorders within the Class

Depressive Disorders

Organization of this Blog Series

The Depressive Disorders’ Blog Series has four parts:  Part One will cover Specifiers for Depressive Disorders; Part Two differentiates Major Depressive Disorder and Persistent Depressive Disorder; Part Three details Disruptive Mood Dysregulation Disorder and Premenstrual Dysphoric Disorder; and Part Four describes Depressive Disorder Due to Another Medical Condition, Substance/Medication-Induced Depressive Disorder, Other Specified Depressive Disorder, and Unspecified Depressive Disorder.

Click HERE to read the introduction to this blog series, Mental Health Diagnoses!, which covers how diagnosis using the Diagnostic and Statistical Manual- 5 works.

Stay Tuned for Part One!

References

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013. Web. [access date: 24 April 2018]. dsm.psychiatryonline.org

Part Four of Bipolar and Related Disorders

The final installment of Bipolar and Related Disorders describes Other Specified Bipolar and Related Disorder and Unspecified Bipolar and Related Disorder.  Diagnosis with one of these disorders is reserved for individuals who do not meet the full criteria for any of the Bipolar and Related Disorders, but whose symptoms cause “significant distress or impairment in social, occupational, or other important areas of functioning” (Diagnostic and Statistical Manual of Mental Disorders, 2013).

Other Specified Bipolar and Related Disorder

The Other Specified Bipolar and Related Disorder diagnosis is applied when the diagnosing professional chooses to specify why the individual does not meet the full criterion for the disorders within this class.  This diagnosis is appropriate when the individual has the symptoms of the mood episodes but does not meet the necessary time constraints for diagnosis.

There are four specifications:  short-duration hypomanic and major depressive episodes, hypomanic episodes with insufficient symptoms and major depressive episodes, hypomanic episode without prior major depressive episode, and short-duration cyclothymia.

An individual with ‘short-duration hypomanic and major depressive episodes’ experiences symptoms of both hypomania and depression, but not simultaneously, and for less that four days.  The ‘hypomanic episodes with insufficient symptoms and major depressive episodes’ specification is used when the symptoms of both mood episodes last less than four days and their presence does not overlap.

‘Hypomanic episode without prior major depressive episode’ is given when an individual has experienced “one or more hypomanic episodes but has never met full criteria for a major depressive episode or a manic episode” (Diagnostic and Statistical Manual of Mental Disorders, 2013).  Finally, the specification of ‘short-duration Cyclothymia’ is given when the symptoms of Cyclothymic Disorder have been present for less than 24 months.

Unspecified Bipolar and Related Disorder

This diagnosis is applied when the diagnosing professional chooses not to specify why the individual does not meet the full criterion for the disorders within this class and/or when there is not enough information available to make a specified diagnosis.  An Unspecified Bipolar and Related Disorder diagnosis is appropriate when an individual receives mental health care in a time-limited setting such as an emergency room.

This concludes the third class of Mental Health Diagnoses!  We hope you are more knowledgeable about Bipolar and Related Disorders, that you feel inspired to share what you have learned with others, and that you will help us stop the stigma and start a conversation about mental illness and mental health!

 

Up Next!

Introduction to Depressive Disorders!

 References

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013. Web. [access date: 13 April 2018]. dsm.psychiatryonline.org

 

Part Three of Bipolar and Related Disorders

Part Three of Bipolar and Related Disorders details Cyclothymic Disorder, Substance/Medication-Induced Bipolar and Related Disorder, and Bipolar and Related Disorder Due to Another Medical Condition.

Diagnosis with one of these disorders requires that their respective symptoms cause “significant distress or impairment in social, occupational, or other important areas of functioning” (Diagnostic and Statistical Manual of Mental Disorders, 2013).

Cyclothymic Disorder

Cyclothymic Disorder is related to Bipolar Disorders because it is characterized by periods of hypomanic and depressive symptoms.  An individual cannot be diagnosed with Cyclothymic Disorder if they have met the full requirements for a manic, hypomanic, or depressive episode within their lifetime.  These mood episodes require that an individual experience a minimum number of symptoms within a specific time frame.  Click HERE for information on classifying mood episodes.

What exactly classifies Cyclothymic Disorder?  Adults must experience numerous periods of hypomanic and depressive symptoms within two years, the periods must be “present for at least of half the time”, and the symptoms must not subside “for more than 2 months at a time” (Diagnostic and Statistical Manual of Mental Disorders, 2013).  The same criterions are needed to diagnose children and adolescents, but the symptoms only need to be present for one year.

Diagnosis also requires that the hypomanic and depressive symptoms are not better explained by any of the Schizophrenia Spectrum and Other Psychotic Disorders; and, that the symptoms are not attributable to the physiological effects of medication, substance abuse, or another medical condition such as hyperthyroidism.  It is important to mention issues with the thyroid gland because the effect of its imbalance mimics the characteristics of Cyclothymic and other Depressive Disorders.

Substance/Medication-Induced Bipolar and Related Disorder

Substance/Medication-Induced Bipolar and Related Disorder is characterized by noticeable and continuous disturbance in mood.  These moods can be “elevated, expansive, irritable, with or without depressive [symptoms, and/or] markedly diminished interest or pleasure in all, or almost all, activities” (Diagnostic and Statistical Manual of Mental Disorders, 2013).

Diagnosis with Substance/Medication-Induced Bipolar and Related Disorder requires that there is evidence of two things:  one, the individual’s “symptoms develop during or soon after substance intoxication or withdrawal or after exposure to a medication”; and two, that “the involved substance/medication is capable of producing the symptoms” (Diagnostic and Statistical Manual of Mental Disorders, 2013).  Evidence can be acquired through medically reported client history, the results of a physical examination, or the conclusions of laboratory tests.

The symptoms of Substance/Medication-Induced Bipolar and Related Disorder should be better explained by the criterion for another Bipolar or Related Disorder.  Determining whether or not the symptoms are due to a substance or medication requires the diagnosing professional to inquire about the presence of mood episodes prior to the use of the substance or medication.

Finally, symptoms must not “occur exclusively during the course of a delirium,” which is characterized by incoherence of thought and speech and restlessness.  (Diagnostic and Statistical Manual of Mental Disorders, 2013).

Bipolar and Related Disorder Due to Another Medical Condition

Bipolar and Related Disorders Due to Another Medical Condition is characterized by noticeable and continuous periods of “abnormally elevated, expansive, or irritable mood and abnormally increased activity or energy” (Diagnostic and Statistical Manual of Mental Disorders, 2013).  Diagnosis with this disorder means that the disturbance supersedes the symptoms of the medical condition.

Diagnosis also requires that “there is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct pathophysiological consequence of another medical condition”.  The symptoms of Bipolar and Related Disorders Due to Another Medical Condition should not be better explained by the criterion for another mental disorder and the “disturbance does not occur exclusively during the course of a delirium” (Diagnostic and Statistical Manual of Mental Disorders, 2013).

Stay Tuned for Part Four!

Part Four of Bipolar and Related Disorders describes Other Specified Bipolar and Related Disorder, and Unspecified Bipolar and Related Disorder.

References

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013. Web. [access date: 13 April 2018]. dsm.psychiatryonline.org

Part Two of Bipolar and Related Disorders

Part Two of Bipolar and Related Disorders compares and contrasts Bipolar I and Bipolar II Disorders.  Characteristics of manic, hypomanic, and depressive episodes are described below, as well as the similarities and differences between Bipolar I and Bipolar II Disorders.

Characteristics of Mania and Hypomania

The Diagnostic and Statistical Manual of Mental Disorders (2013) lists the following characteristics of mania or hypomania:

  1. “Elevated, expansive mood
  2. Inflated self-esteem or grandiosity
  3. More talkative than usual or pressure to keep talking
  4. Flight of ideas or subjective experience [of racing thoughts]
  5. Increase in energy or goal-directed activity
  6. Increased or excessive involvement in activities that have a high potential for painful consequences.  [Examples of this include, but are not limited to, buying sprees and sexual indiscretions.]
  7. Decreased need for sleep”.

Meeting the criteria for mania or hypomania requires that three or more of the previously mentioned symptoms are present and that they “represent a noticeable change from usual behavior” (Diagnostic and Statistical Manual of Mental Disorders, 2013).

You may be asking, “If mania and hypomania have the same characteristics, what, if anything, makes them different?”

One, the amount of time the symptoms are present varies.  Characteristics or symptoms that are “present most of the day, nearly every day” for at least one week indicate a manic episode.  The presence of characteristics or symptoms for “at least 4 consecutive days and present most of the day, nearly every day” indicates a hypomanic episode (Diagnostic and Statistical Manual of Mental Disorders, 2013).

Two, symptoms that cause social or occupational impairment and/or necessitate hospitalization are considered manic.  If the symptoms are not severe enough to disrupt social and occupational functioning, they are considered hypomanic.

Characteristics of Depression

The Diagnostic and Statistical Manual of Mental Disorders (2013) lists the following characteristics of depression:

  1. “Depressed mood
  2. Markedly diminished interest or pleasure in all, or almost all, activities
  3. Significant weight loss when not dieting, weight gain, or decrease or increase in appetite
  4. Insomnia or hypersomnia
  5. Psychomotor agitation or retardation
  6. Fatigue or loss of energy
  7. Feelings of worthlessness or excessive or inappropriate guilt
  8. Diminished ability to think or concentrate, or indecisiveness
  9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, a suicide attempt, or a specific plan for committing suicide”.

A depressive episode requires that the individual experience five or more of the nine previously mentioned symptoms for most of the day and nearly every day for at least two weeks, and that at least one of the symptoms is either ‘depressed mood’ or ‘loss of interest or pleasure’.  Also, the presence of the symptoms of depression must represent a change in previous functioning that causes “significant distress or impairment in social, occupational, or other important areas of functioning” (Diagnostic and Statistical Manual of Mental Disorders, 2013).

 Similarities Between Bipolar I and Bipolar II Disorders

There are several criterions that both Bipolar I and Bipolar II have in common.  First, their mood episodes (manic, hypomanic, or depressive) must not be “better explained by Schizoaffective Disorder, Schizophrenia, Schizophreniform Disorder, Delusional Disorder, Other Specified or Unspecified Schizophrenia Spectrum, and Other Psychotic Disorder” (Diagnostic and Statistical Manual of Mental Disorders, 2013).  Second, “the mood episodes are not attributable to the physiological effects of a substance or another medical condition” (Diagnostic and Statistical Manual of Mental Disorders, 2013).  Third, both disorders can be further specified based on the presence and patterns of additional symptoms.  Details regarding these specifiers are described in Part One of Bipolar and Related Disorders.

Bipolar I Disorder

A diagnosis of Bipolar I means an individual has experienced at least one manic episode.  The same individual may or may not experience a hypomanic or depressive episode prior to or after the manic episode.  It is important to note that a person may experience all three mood episodes in their lifetime, but not simultaneously.  The combination of mood episodes is one of the things that differentiate Bipolar I and Bipolar II Disorders.

Bipolar II Disorder

A diagnosis of Bipolar II means an individual has experienced at least one hypomanic episode; at least one major depressive episode; and that they never experienced a manic episode.  Diagnosis also requires that the individual’s depressive symptoms and/or their swing from depression to hypomania “cause clinically significant distress or impairment in social, occupational, or other important areas of functioning” (Diagnostic and Statistical Manual of Mental Disorders, 2013).

Stay Tuned for Part Three!

Part Three of Bipolar and Related Disorders details Cyclothymic Disorder, Substance/Medication-Induced Bipolar and Related Disorder, and Bipolar and Related Disorder Due to Another Medical Condition.

References

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013. Web. [access date: 4 April 2018]. dsm.psychiatryonline.org

 

Part One of Bipolar and Related Disorders

Part One of Bipolar and Related Disorders

Part One of Bipolar and Related Disorders covers specifiers.  Specifiers are used to further define the characteristics that accompany a mental health diagnosis.  Due to the polar nature (depression and mania) of Bipolar and Related Disorders, there are several options to specify an individual’s diagnosis.  These specifiers are important because diagnosis determines the course of treatment.  The following specifiers are defined below:  anxious distress, atypical features, catatonia, melancholic features, mixed features, peripartum onset, psychotic features, rapid cycling, and seasonal pattern.

Bipolar and Related Disorders is the third diagnostic class being covered in the Mental Health Diagnosis! blog series.  If you missed the introduction to the series click HERE to learn how the Diagnostic and Statistical Manual-5 works.  Click HERE to read the introduction to Bipolar and Related Disorders where we cover important concepts such as mania, hypomania, and depression!

 Specifiers for Bipolar and Related Disorders

Anxious Distress

The anxious distress specifier is added to a diagnosis if the individual experiences two or more ‘anxious’ features during their most recent manic, hypomanic, or depressive episode.  The number of symptoms experienced determines the severity of the distress.  Experiencing two symptoms is considered mild; three symptoms is moderate; four or five symptoms is moderate to severe; and, experiencing four to five symptoms with motor agitation (involuntary and meaningless movement) is classified as severe.  The Fifth Edition of the Diagnostic and Statistical Manual (DSM-5) outlines anxious features as follows:  tension, restlessness, worry that makes concentration difficult, fear something horrible will occur, and feeling as though they may lose control.

Atypical Features

The atypical features specifier is added to a diagnosis when the following features are prevalent during the most current major depressive episode.  The first necessary feature is mood reactivity which describes how an individual’s “mood brightens in response to actual or potential positive events” (Diagnostic and Statistical Manual of Mental Disorders, 2013).  Secondly, the individual experiences two or more of the following features:  “significant weight gain or increase in appetite; hypersomnia; leaden paralysis, [or a heavy feeling in the limbs]; and a long-standing pattern of interpersonal rejection sensitivity that results in significant social or occupational impairment” (Diagnostic and Statistical Manual of Mental Disorders, 2013).  Finally, the individual must not meet the criteria for the “with melancholic features” or “with catatonia” specifiers, which are described below, during the same depressive episode.

Catatonia

Catatonia or catatonic behavior is a noticeable decrease in the level and intensity of which an individual interacts with or responds to their environment.  The catatonia specifier is applied to a Bipolar and Related Disorders diagnosis when catatonic features are present during the individual’s manic or depressive episode.  Details about catatonia can be found in Part Three of Schizophrenia Spectrum and Other Psychotic Disorders. 

 Melancholia Features

There are two criteria for meeting the melancholia features specifier.  Criterion A requires that the individual experience either loss of pleasure in the majority of their activities or a “lack of reactivity to usually pleasurable stimuli” (Diagnostic and Statistical Manual of Mental Disorders, 2013).  Criterion B requires that the individual experience three or more of the following features:

  1. “A distinct quality of depressed mood or so-called empty mood
  2. Depression that is regularly worse in the morning
  3. Early-morning awakening (i.e., at least 2 hours before usual awakening)
  4. [Noticeable] psychomotor agitation or retardation
  5. Significant anorexia or weight loss
  6. Excessive or inappropriate guilt”

(Diagnostic and Statistical Manual of Mental Disorders, 2013).

Psychotic Features

The psychotic features specifier is added to a diagnosis when the individual experiences delusions and hallucinations during a manic, hypomanic, or depressive episode.  Delusions are beliefs that remain even when there is evidence that is contrary.  Hallucinations occur when an individual involuntarily perceives an experience without any external stimuli.  Details regarding delusions and hallucinations are described in the Introduction to Schizophrenia Spectrum and Other Psychotic Disorders.

Seasonal Pattern

The seasonal pattern specifier is used to describe the “lifetime pattern of mood episodes” (Diagnostic and Statistical Manual of Mental Disorders, 2013).  A mood episode is a phrase used when generalizing manic, hypomanic, and depressive episodes.  The seasonal pattern specifier is added to a diagnosis when the mood episode occurs during the same time of year.  The DSM-5 outlines four criteria that qualify symptoms for the seasonal pattern specifier.

One, the relationship between the change of temporal season and the change in mood from depression to mania, depression to hypomania, and/or vice versa occurs regularly and during the same time of year.  Two, the individual goes into full remission with the change of temporal season or at a particular time of year.  An example of this is when depression lifts in the spring.  Three, the individual’s mood episodes do not have non-seasonal changes.  Four, seasonal mood episodes significantly outnumber any non-seasonal mood episodes during the individual’s lifetime.

Specifiers for Bipolar I and Bipolar II Disorders

The following specifiers are applied to Bipolar I and Bipolar II Disorders.  We will compare and contrast Bipolar I and Bipolar II Disorders in part two of this series.

Mixed Features

There are two subcategories for the mixed features specifier:  “manic or hypomanic episode, with mixed features” and “depressive episode, with mixed features”.  They each have four criterions, which are listed as A through D.  Criterions B through D are the same for both specifiers, while Criterion A differs.

Criterion A for “manic or hypomanic episode, with mixed features” necessitates that the individual meet the full requirements for a manic or hypomanic episode and that the individual have at least three symptoms of depression.

Criterion A for “depressive episode, with mixed features” necessitates that the individual meet the full requirements for a major depressive episode and that the individual have at least three manic and hypomanic symptoms.

Criterion B requires that the symptoms of depression, mania and/or hypomanic are a change from the person’s typical behavior and that the changes are observable by others.  Criterion C dictates that the diagnosis “manic episode, with mixed features” is used specifically for persons whose symptoms meet full criteria for mania and depression.  Criterion D states that the “symptoms are not attributable to the physiological effects of a substance” (Diagnostic and Statistical Manual of Mental Disorders, 2013).

Rapid Cycling

Specifying a disorder as rapid cycling requires that the individual experience at least four mood episodes within a twelve-month period.  The mood episodes must meet the minimum criteria for mania, hypomania, or depression.

Peripartum Onset

The peripartum onset specifier is reserved for describing the symptoms of a manic, hypomanic, or major depressive episode that began during pregnancy or within four weeks of delivery (Diagnostic and Statistical Manual of Mental Disorders, 2013).

Stay Tuned for Part Two where we cover Bipolar I and Bipolar II Disorders!

References

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013. Web. [access date: 21 March 2018]. dsm.psychiatryonline.org

Introduction to Bipolar and Related Disorders

What classifies a disorder as Bipolar?

Bipolar refers to two poles, or opposite ends of a spectrum.  One end of the pole is mania.  This is an elevated mood where an individual is described as “up”.  Depression is on the other end of the pole.  Having a depressed mood or loss of interest in activities is considered “down”.  If an individual is diagnosed as bipolar, they have experienced both mania and depression for specific periods of time.

Why not include Bipolar and Related Disorders with Depressive Disorders?

Depressive Disorders are unipolar.  Instead of having both an “up” and a “down” period, the individual only experiences a “down”.  Details regarding Depressive Disorders will be covered in the next blog series.

Are Bipolar Disorders and Manic-Depressive Disorder the same?

Manic Depression is no longer a Diagnostic and Statistical Manual diagnosis, however, the majority of its symptoms are now considered Bipolar I Disorder.  Two required criteria that were included for Manic Depression are not included in the Bipolar I Disorder criterions:  presence of psychosis, and “the lifetime experience of a major depressive episode” (Diagnostic and Statistical Manual of Mental Disorders, 2013).  Details regarding Bipolar I Disorder are outlined in Part Two of Bipolar and Related Disorders.

Names of the Disorders within the ClassBipolar Disorders

Each of these disorders has at least one common criterion:  “the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning” (Diagnostic and Statistical Manual of Mental Disorders, 2013).

Descriptions of Important Terms

The disorders within this class have common features:  mania, hypomania, and depression.  The combination of these three features and the severity of their episodes (a minimum and/or maximum amount of time that the symptoms are present) determine which disorder the client is presenting.  The Diagnostic and Statistical Manuel 5 (DSM-5) defines these features as follows:

 Mania:  “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”;

Hypomania:  “abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day”;

Depression:  “depressed mood or loss of interest or pleasure” that has been “present during the same 2-week period and represents a change from previous functioning” (2013).

Further details describing manic episodes, hypomanic episodes, and depressive episodes are discussed in Part Two of Bipolar and Related Disorders where we compare and contrast Bipolar I and Bipolar II Disorders.

Organization of this Blog Series

The Bipolar and Related Disorders’ Blog Series will have four parts:  Part One will cover Specifiers for Bipolar and Related Disorders; Part Two differentiates Bipolar I Disorder and Bipolar II Disorder; Part Three details Cyclothymic Disorder, Substance/Medication-Induced Bipolar and Related Disorder, and Bipolar and Related Disorder Due to Another Medical Condition; and Part Four describes Other Specified Bipolar and Related Disorder, and Unspecified Bipolar and Related Disorder.

Click HERE to read the introduction to this blog series, Mental Health Diagnoses!, which covers how diagnosis using the Diagnostic and Statistical Manual- 5 works.

Stay Tuned for Part One of Bipolar and Related Disorders!

Reference

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013. Web. [access date: 14 March 2018]. dsm.psychiatryonline.org

Part Three of Schizophrenia Spectrum and other Psychotic Disorders

Part Three of Schizophrenia Spectrum and Other Psychotic Disorders will cover Catatonia Associated With Another Mental Disorder (Catatonia Specifier), Catatonic Disorder Due to Another Medical Condition, and Delusional Disorder.

Click HERE to read the Introduction to Schizophrenia Spectrum and Other Psychotic Disorders, which gives definitions to important terms and an overview of the disorders within this class.

 What is Catatonia?

Catatonia or catatonic behavior is a noticeable decrease in the level and intensity of which an individual interacts with or responds to their environment.

 Symptoms of Catatonia

The following list contains brief descriptions of catatonia symptoms.

  • Stupor: a daze; not actively responding to the surrounding environment
  • Catalepsy: a trance; loss of sensation and consciousness; rigid body posture
  • Waxy flexibility: decreased response to external stimuli; remaining immobile/resisting someone who tries to change their body position
  • Mutism: little to no verbal response
  • Negativism: “opposition to or no response to instructions or external stimuli” (DSM)
  • Posturing: “spontaneous and active maintenance of a posture against gravity” (DSM). An example of this is an individual standing on one leg and with one or both arms extended over their head.
  • Mannerism: repeating a ‘normal’ gesture, such as clearing the throat or twirling hair around a finger, in an exaggerated manner
  • Stereotypy: “repetitive, abnormally frequent, non-goal-directed movements” (DSM). An example of this is arm flapping or rocking the body from side to side.
  • Agitation: anxiety or disturbance that is not influenced by external stimuli
  • Grimacing: a twisted or out of shape facial expression
  • Echolalia: mimicking another’s speech
  • Echopraxia: mirroring a person’s movements

(Diagnostic and Statistical Manual of Mental Disorders, 2013)

 What is a specifier?

Specifiers are used when an individual meets the criteria for a diagnosis, yet they also experience multiple symptoms of another mental health diagnosis.  Specifiers can be a description added to a diagnosis or, if the symptoms are severe, an added specifier diagnosis is given.  It is important to note that the individual would be given an additional mental health diagnosis if they met all criteria.

 Catatonia Associated With Another Mental Disorder (Catatonia Specifier)

Catatonia Associated With Another Mental Disorder, or Catatonia Specifier, is used when an individual experiences three or more of the previously mentioned symptoms of catatonia.  It is typically seen in conjunction with depressive, psychotic, bipolar, and/or neurodevelopmental disorders.  Due to the range of catatonic symptoms, the diagnosing professional must rule out medical conditions and medications that contribute to catatonia prior to diagnosis.

 Catatonic Disorder Due to Another Medical Condition

There are five criteria for diagnosis with Catatonic Disorder Due to Another Medical Condition:  One, the individual must experience three or more of the catatonia symptoms that were previously mentioned; Two, there is “evidence from the history, physical examination, or laboratory findings that the disturbance is the direct consequence of another medical condition”; Three, the symptoms are “not better explained by another medical disorder”; Four, the symptoms do not occur only during delirium; and Five, the presence of symptoms cause “distress or impairment in social, occupational, or other important areas of functioning” (Diagnostic and Statistical Manual of Mental Disorders, 2013).

 Delusional Disorder

The Diagnostic and Statistical Manual of Mental Disorders describes five types of delusions:  erotomanic, grandiose, jealous, persecutory, somatic, and nihilistic.  For detailed descriptions of these delusions, click HERE, where you will be redirected to the Introduction to Schizophrenia Spectrum and Other Psychotic Disorders blog post.

Delusions are beliefs that remain even when evidence that is contrary to the belief is presented.  Diagnosis with Delusional Disorder involves individuals experiencing one or more delusions for at least one month.  Delusions can be present in persons who have Schizophrenia and/or in persons who are experiencing a manic or major depressive episode.  Because the presence of delusions is one of the criteria for diagnosing Schizophrenia, diagnosis with Delusional Disorder requires that the individual has never met the criterion for Schizophrenia. (Click HERE to review the diagnostic criteria for Schizophrenia).  In addition, diagnosis with Delusional Disorder requires that the manic or major depressive disorder be briefer that the duration of the delusional period.

Aside from the “impact of the delusion(s) or its [consequences], functioning is not [noticeably] impaired, and behavior is not obviously bizarre or odd” (Diagnostic and Statistical Manual of Mental Disorders, 2013).  A delusion is classified as bizarre if it is highly improbable and if another individual from the same culture as the person experiencing the delusion does not understand it.  Finally, the symptoms and its accompanying disturbances are not better explained by another medical condition or the effects of a substance, such as drugs of abuse or prescribed medications.

 Up Next!

Introduction to Bipolar and other Related Disorders!

References

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013. Web. [access date: 2 March 2018]. dsm.psychiatryonline.org

Part Two of Schizophrenia Spectrum and Other Psychotic Disorders

Part Two of Schizophrenia Spectrum and Other Psychotic Disorders will cover Brief Psychotic Disorder, Psychotic Disorder Due to Another Medical Condition, and Substance/Medication-Induced Psychotic Disorder.

Click HERE to read the introduction to this blog series, Mental Health Diagnoses!, which covers how diagnosis using the Diagnostic and Statistical Manual- 5 (DSM-5) works.

 What is Psychosis?

The word ‘psychotic’ is often used in casual conversation as a derogatory slang to ‘poke’ or ‘make fun’ of someone.  Doing so is not only offensive to the individual being called psychotic, but it is also offensive to persons who are diagnosed with a psychotic disorder.  In addition, the term ‘psychotic’ is often times being used incorrectly.

Psychotic is typically defined as an individual who experiences or suffers from a psychosis.  It is appropriate to say that an individual experiences psychosis and/or an individual has been diagnosed with a psychotic disorder.

So, what is psychosis? Psychosis is the presence of one or more of the five domains:  hallucinations, delusions, disorganized speech, or grossly disorganized behavior or catatonic behavior.  Each of these characteristics were defined in detail in the Introduction to Schizophrenia Spectrum and other Psychotic Disorders blog entry. Click HERE for a refresher.

What differentiates Psychotic Disorders from the disorders of the Schizophrenia Spectrum?

You may be asking yourself, “If Psychotic Disorders are also classified by the five domains, how do they differ from the Schizophrenia Spectrum disorders within this class?”  The characteristics are similar, but they differ in duration, presence, and severity of symptoms.  When diagnosing an individual with a Psychotic Disorder, the helping professional must also assess their client’s cognition, their level of depression, and the presence and/or severity of manic symptoms in order to rule out the schizophrenia disorders (Diagnostic and Statistical Manual of Mental Disorders, 2013).

 Similarities between Substance/Medication-Induced Psychotic Disorder and Psychotic Disorder due to Another Medical Condition

Substance/Medication-Induced Psychotic Disorder and Psychotic Disorder due to Another Medical Condition are similar in four ways:

  1. They require the individual to have either delusions or hallucinations;
  2. There “is evidence from the [client’s social and medical] history, physical examination, or laboratory findings” of delusions and hallucinations;
  3. Their symptoms are not attributed to another mental disorder (like Schizophrenia) and/or the effects of another medical condition (like dementia);
  4. The disturbances cause “clinically significant distress or impairment in social, occupational, or other important areas of functioning” (Diagnostic and Statistical Manual of Mental Disorders, 2013).

 Psychotic Disorder Due to Another Medical Condition

Diagnosis with Psychotic Disorder due to Another Medical Condition occurs when an individual has either delusions or hallucinations that are caused by a medical condition.  These disturbances must not “occur exclusively during the course of a delirium,” which is incoherence of thought and speech, illusions, and restlessness (Diagnostic and Statistical Manual of Mental Disorders, 2013).

As previously mentioned, diagnosis requires that there be evidence that connects the psychosis to a medical condition.  Examples of medical conditions that cause psychosis include, but are not limited to:  brain diseases, such as Parkinson’s or Huntington’s disease; brain tumors; brain cysts; Dementia; Alzheimer’s Disease; Stroke; and, Human Immunodeficiency Virus, or HIV.

 Substance/Medication-Induced Psychotic Disorder

In addition to the previously mentioned criteria, diagnosis with Substance/Medication-Induced Psychotic Disorder requires that delusions or hallucinations develop during or soon after an individual becomes intoxicated from a substance, withdraws from a substance, or after the individual has been exposed to a medication (Diagnostic and Statistical Manual of Mental Disorders, 2013).  It is important to note that the substance or medication that the person has ingested or been exposed to is not capable of producing delusions or hallucinations on their own.  This means that a person who takes LSD does not qualify for this diagnosis because LSD is known to cause hallucinations.

 Brief Psychotic Disorder

A person is diagnosed with Brief Psychotic Disorder when they go from a ‘normal’ “nonpsychotic state [of mind] to a clearly psychotic state [of mind] within two weeks” (Diagnostic and Statistical Manual of Mental Disorders, 2013).  This means that the person suddenly begins to experience at least one of the five domains that characterize Schizophrenia Spectrum and Other Psychotic Disorders (see above).  These behaviors continue for at least one day but not more than one month.  If the symptoms continue after one month, meaning the individual does not return to their normal nonpsychotic state of mind, then they will qualify for another disorder within this class.  As with all disorders within the DSM-5, it is necessary to consider whether or not another mental disorder, the physiological effects of a substance, and/or the effects of another medical condition are affecting the individual.

Stay tuned for the third and final installment of Schizophrenia Spectrum and other Psychotic Disorders!

Part three will cover Catatonia Associated With Another Mental Disorder (Catatonia Specifier), Catatonic Disorder Due to Another Medical Condition, and Delusional Disorder.

References

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013. Web. [access date: 20 January 2018]. dsm.psychiatryonline.org

 

Part One of Schizophrenia Spectrum and Other Psychotic Disorders

Part One of the Schizophrenia Spectrum and Other Psychotic Disorders covers the disorders on the Schizophrenia Spectrum.  Schizoaffective Disorder, Schizophrenia, Schizophreniform Disorder, and Schizotypal Disorder (which is technically a personality disorder) are described below.

Click HERE if you missed the Introduction to Schizophrenia Spectrum and Other Psychotic Disorders or click HERE if you would like to review the blog that introduces this series on Mental Health Diagnoses!

What do these disorders have in common?

Schizoaffective Disorder, Schizophrenia, and Schizophreniform Disorder have similar characteristics.  We will cover what they have in common, and then we will discuss their differences.

The first common criterion for diagnosis on the Schizophrenia Spectrum is that the symptoms of each disorder must not be better explained by another medical condition or the effects of substance, such as drugs of abuse or prescribed medications.  It is always important to rule out other diagnoses because treatments for mental disorders are based on the disorder’s symptoms and typical patterns of progression.

Both Schizophrenia and Schizophreniform have identical initial criteria, or Criterion A.  This initial criterion lists the five domains that characterize Schizophrenia Spectrum:  delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms.  The individual has to experience two or more of the five characteristics and at least one of these characteristics must be delusions, hallucinations, or disorganized speech (Diagnostic and Statistical Manual of Mental Disorders, 2013).  A person cannot be diagnosed with Schizophrenia or Schizophreniform if they are only experiencing catatonia and/or negative symptoms.

An individual that has been diagnosed with Schizoaffective Disorder must meet the same initial criteria mentioned above in addition to experiencing a major mood episode.  These major mood episodes can be manic; which is characterized by high energy, or they can be a major depressive episode; which is characterized by loss of energy and pleasure, as well as feelings of hopelessness.

Schizotypal Disorder is both a Schizophrenia Spectrum Disorder and a Personality Disorder.  We will mention it here and again, but in further detail, when we cover disorders of personality.

Schizophrenia

Symptoms of Schizophrenia typically develop in early adolescence.  Individuals begin to experience emotional, cognitive, and behavioral disruptions that significantly affect their daily lives.  An individual must meet all six of the criterion set forth by the Diagnostic and Statistical Manuel 5 (DSM-5) for diagnosis of Schizophrenia:

One, a person must experience two or more of the five characteristics of the schizophrenia spectrum. Two, the symptoms must significantly affect functioning within their interpersonal relationships, with their ability to care for themselves, and with their occupational duties.  Three, the symptoms must persist for at least six months.  Four, Schizoaffective Disorder, which is described below, and Bipolar Disorders that have psychotic features have been ruled out.  Five, the individual is not experiencing the effects of another medical condition and/or the affects of substance abuse.  Finally, the sixth criterion is in regards to adding the diagnosis of Schizophrenia to an individual who is also diagnosed with “autism spectrum disorder or a communication disorder of childhood onset” (Diagnostic and Statistical Manual of Mental Disorders, 2013).  In this situation, Schizophrenia can only be added if all over criterion have been met and “if prominent delusions or hallucinations are also present for at least one month” (Diagnostic and Statistical Manual of Mental Disorders, 2013).

Schizophreniform Disorder

The symptoms of Schizophreniform Disorder are the same as the symptoms of Schizophrenia Disorder.  The two disorders differ in the duration of the presence of their symptoms.  Where Schizophrenia’s symptoms must persist for at least six months, symptomatic episodes in Schizophreniform last at least one month but less that six months.  This means that an individual has the opportunity to “recover” from the episode, and it also means that more episodes can occur.

Just like the other disorders, it is necessary to not only rule out the other Schizophrenia Spectrum disorders, but to also rule out “the physiological effects of a substance, a drug of abuse, a [prescribed] medication, or another medical condition (Diagnostic and Statistical Manual of Mental Disorders, 2013).

Schizoaffective Disorder

A diagnosis with Schizoaffective Disorder requires that the individual experience:  a major mood episode; delusions, hallucinations, or disorganized speech; and, grossly disorganized behavior, catatonic behavior, or negative symptoms (as defined previously, are symptoms that take away from an individuals functioning).  These mood episodes are what distinguish Schizoaffective Disorder from the other Schizophrenia Spectrum Disorders.

Mania, which is commonly associated with the bipolar disorders, is characterized by persistent elevated mood, irritability, and increased activity for the majority of the day, almost every day, for at least a week (Diagnostic and Statistical Manual of Mental Disorders, 2013).  Symptoms of a depressed mood include feelings of worthlessness, difficulties thinking and/or concentrating, and even thoughts of suicide.

These combined symptoms of mania, depression, delusions, and hallucinations can be present in depressive disorders.  Because of this, a diagnosis with Schizoaffective Disorder requires that the helping professional consider the individual’s entire course of symptom development.  At some point during the lifetime of the illness, the diagnosed individual must experience at least two weeks of both delusions and hallucinations, without also experiencing symptoms of depression.

However, maintaining the Schizoaffective Diagnosis requires that the “episodes of depression or mania be present for the majority of the total duration of the illness” (Diagnostic and Statistical Manual of Mental Disorders, 2013).  These required time constraints help prevent misdiagnosis.

Schizotypal (Personality) Disorder

Schizotypal Personality Disorder is mentioned in this series due to characteristics such as delusions and perceptual alterations.  The schizotypal pattern of behavior and its symptoms become present in early adulthood.

Schizotypal Personality Disorder is characterized by deficits in close social and interpersonal relationships and “cognitive or perceptual distortions and eccentricities of behavior” (Diagnostic and Statistical Manual of Mental Disorders, 2013).  The DSM-5 lists nine characteristics for Schizotypal Disorder; and a diagnosis requires an individual experience at least five:

One, “ideas of reference” or incorrectly interpreting events using meaning that is only specific to themselves.  Two, “odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms”, which includes thinking they have special powers or that they can control people and objects with their thoughts (Diagnostic and Statistical Manual of Mental Disorders, 2013).  The third characteristic is perceptual experiences.  These are brief visual or auditory perceptions such as feeling watched or hearing someone whisper their name.

Four, speaking or thinking in vague, overelaborate, or metaphorical terms.  The DSM-5 (2013) gives an example of this manner of speaking as the individual stating they were “not ‘talkable’ at work”.  The fifth characteristic, “suspiciousness or paranoid ideation” is most similar to symptoms of Schizophrenia Spectrum Disorders.  This paranoia can manifest as believing friends, family, and/or associates are ‘out to get them’.

The sixth and seventh characteristics are “inappropriate or constricted affect” and “behavior or appearance that is odd, eccentric, or peculiar” (Diagnostic and Statistical Manual of Mental Disorders, 2013).  These are typically present while the individual is interacting with peers.  They have facial expressions and body movements that are inappropriate for the setting or the conversation, and/or their style of dress may be described as unkempt.

Eight, the individual does not have close friends outside of their parents and siblings.  The ninth characteristic involves the individual experiencing extreme and disproportionate social anxiety.  This anxiety does not lessen, but it increases and fosters paranoia as they continue to stay within the setting.

Finally, symptoms associated with Schizotypal Personality Disorder must not occur “during the course of Schizophrenia, a bipolar disorder or depressive disorder with psychotic features, another psychotic disorder, or Autism Spectrum Disorder” (Diagnostic and Statistical Manual of Mental Disorders, 2013).

 Up Next!

Part Two of Schizophrenia Spectrum and Other Psychotic Disorders!

References

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013. Web. [access date: 20 January 2018]. dsm.psychiatryonline.org

 

Introduction to Schizophrenia Spectrum and Other Psychotic Disorders!

What classifies a disorder as a form of Schizophrenia or another Psychotic Disorder?

Schizophrenia and psychosis are more complicated than a person simply hearing voices.  The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders lists five domains that characterize Schizophrenia Spectrum and Other Psychotic Disorders.  They are as follows:  “delusions; hallucinations; disorganized thinking [and/or speech]; grossly disorganized or abnormal motor behavior, including catatonia; and negative symptoms” (Diagnostic and Statistical Manual of Mental Disorders, 2013).

Descriptions of Important Terms

Prior to describing the diagnostic criteria for the Schizophrenia Spectrum and Other Psychotic Disorders, the DSM-5 defines the five domains that characterize the disorders.

Delusions are beliefs that remain even when evidence that is contrary to the belief is presented.  Delusions have many themes, the most common of which are persecutory and referential, which are defined below.

  1. “Persecutory Delusions: belief that one is going to be harmed, harassed, and so forth by an individual, an organization, or another group;
  2. Referential Delusions: belief that certain gestures, comments, environmental cues, and so forth are directed at oneself;
  3. Grandiose Delusions: when an individual believes that he or she has exceptional abilities, wealth, or fame;
  4. Erotomanic Delusions: when an individual believes falsely that another person is in love with him or her, [which is the root of stalking];
  5. Nihilistic Delusions: the conviction that a major catastrophe will occur; and,
  6. Somatic Delusions:  preoccupations regarding health and organ function” (Diagnostic and Statistical Manual of Mental Disorders, 2013).

In addition to these themes, delusions can also be considered bizarre.  A delusion is classified as bizarre if it is highly improbable and if another individual from the same culture as the person experiencing the delusion does not understand it.  There is an emphasis on culture because some cultures have widely held beliefs that are much different than beliefs that are held by the majority culture.

The DSM-5 (2013) gives the following examples to differentiate between bizarre and non bizarre delusions, “the belief that an outside force has removed his or her internal organs and replaced them with someone else’s organs without leaving any wounds or scars.  An example of a nonbizarre delusion is the belief that one is under surveillance by the police, [the FBI, and the CIA], despite a lack of convincing evidence.”

Hallucinations occur when an individual involuntarily perceives an experience without any external stimuli.  These clear and intense perceptions can be sensory, auditory, or visual.  Auditory hallucinations are not the individual’s thoughts, but are instead a distinct voice that is either familiar or unfamiliar to the person.

Mild forms of hallucinations occur as part of our sleep cycle.  Hallucinations that occur when falling asleep are called hypnagogic, and hallucinations that occur when waking up are referred to as hypnopompic.  Although we typically do not remember these hallucinations, both of these are considered normal.  It is important to note that hallucinations that are a result of psychosis occur while an individual’s mind is clear and when they are fully awake.

Disorganized Thinking is determined by listening to the individual’s speech.  An individual’s thinking is considered disorganized when their speech inhibits their ability to effectively communicate.  The DSM-5 (2013) describes three speech patterns that demonstrate disorganized thinking:

  1. “Derailment or Loose Associations: switching from one topic to another [while talking];
  2. Tangentiality: giving answers to questions that may be obliquely related or completely unrelated [and confuse the listener]; and,
  3. Incoherence or ‘Word Salad’: speech that is so severely disorganized that it is nearly incomprehensible”.

Grossly Disorganized or Abnormal Motor Behavior includes a wide range of movements and/or behaviors such as extremely rigid limbs, exceptionally flexible limbs, and holding a blank stare.  These behaviors are typically identified when the individual is attempting to complete a specific task, especially one for daily living.

Catatonia or catatonic behavior is “a marked decrease in reactivity to the environment” (Diagnostic and Statistical Manual of Mental Disorders, 2013). The DSM-5 (2013) describes four types of catatonic behaviors:

  1. negativism, or resistance to instructions;
  2. maintaining a rigid, inappropriate or bizarre posture;
  3. mutism and stupor, which is a complete lack of verbal and motor responses; and,
  4. catatonic excitement, or purposeless and excessive motor activity without obvious cause.”

Other examples of catatonic behavior include, but are not limited to, “repeated stereotyped movements, staring, grimacing, and the echoing of speech” (Diagnostic and Statistical Manual of Mental Disorders, 2013).  An individual does not have to be on the Schizophrenia Spectrum nor do they have to be diagnosed with a psychotic disorder to experience catatonia.  Catatonic behaviors are also seen in depressive disorders.

Negative Symptoms are symptoms that decrease an individual’s ability to function normally.  Negative symptoms include, but are not limited to, alogia, anhedonia, asociality, avolition, and diminished emotional expression.  The two most prominent negative symptoms seen in schizophrenia spectrum and psychotic disorders are diminished emotional expression and avolition.  The DSM-5 (2013) describes these symptoms as follows:

  1. “Alogia: diminished speech output;
  2. Anhedonia: the decreased ability to experience pleasure from positive stimuli or a degradation in the recollection of pleasure previously experienced;
  3. Asociality: the apparent lack of interest in social interactions;
  4. Avolition: a decrease in motivated self-initiated purposeful activities; and,
  5. Diminished Emotional Expression: reductions in the expression of emotions in the face, eye contact, intonation of speech, and movements of the hand, head, and face that normally give an emotional emphasis to speech”.

Names of the Disorders within the Class

Schizophrenia spectrum disorders

*We will not cover the unspecified or other specified disorders in this blog.

Each of these disorders has at least one common criterion:  “the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning” (Diagnostic and Statistical Manual of Mental Disorders, 2013).  This requirement is typically listed as the last diagnostic criteria for each of the disorders within the class.

Organization of this Blog Series

The Schizophrenia Spectrum and Other Psychotic Disorders blog will have three parts:  Part One will cover Schizoaffective Disorder; Schizophrenia; Schizophreniform Disorder; and Schizotypal (Personality) Disorder.  Part Two will cover Brief Psychotic Disorder; Psychotic Disorder Due to Another Medical Condition; and Substance/Medication-Induced Psychotic Disorder.  Finally, Part Three of Schizophrenia Spectrum and Other Psychotic Disorders will cover Catatonia Associated With Another Mental Disorder (Catatonia Specifier); Catatonic Disorder Due to Another Medical Condition; and Delusional Disorder.

Click HERE to read the introduction to this blog series, Mental Health Diagnoses!, which covers how diagnosis using the Diagnostic and Statistical Manual- 5 (DSM-5) works.

Stay Tuned for Part One!

References

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013. Web. [access date: 20 January 2018]. dsm.psychiatryonline.org