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DSM 5 Exam Study Guide*

Terms in this set (115)

-migrant status
-older fathers
-toxoplasmosis gondii antibodies
-prenatal famine
-lifetime cannabis use
-winter or spring birth

Perinatal Factors:
-increased risk in infants of mothers exposed to influenza during second trimester and birth during winter months

Obstetric Complications:
-preeclampsia
-breech
-other abnormal presentation
-labor > 36 hours or labor < 3 hours
-cord prolapse
-forceps delivery
-(all or > 2)

Age and Sex:
-onset in males is 3-5 years earlier than females
-onset before 10 yrs old is very rare
-onset after 50 yrs old is very rare
-prevalence is equal between boys and girls until puberty
-prevalence is greater in men than women throughout most of adulthood
-prevalence in higher in women after age 45
-no difference in prevalence by the end of life
-women tend to have a less severe course of the illness and are more responsive to antipsychotic drugs

Social Class:
-Lower SES and elevated rate
-cause vs. effect (stress vs. social drift)

Urban:
-incidence higher among children growing up in urban environment

Culture:
-prevalence of schizophrenia is similar across cultures
-course of illness may be more benign in developing countries compared to industrialized nations

Family:
-expressed emotion-instrusive, critical, hostile
-etiology vs. effect of ill person on family

Stressful life events:
-high rates of psychotic disorders among new immigrants
-rates approximate native born over time
-higher rate of stressful events immediately prior to hospitalization

Cannabis use:
-increased risk of psychotic disorder in cannabis users (OR is ~1.41)
-dose related effect - greater risk among those who use most frequently (OR is ~2.09)
Longterm Outcome
-67% have at least 1 relapse over 15 years
-better services produce better outcomes
-review of 10 long-term (>20yrs) follow up studies: 21-57% showed periodic episodes of recovery (improved symptoms, greater social, educational and occupational functioning)
-poor ability to predict outcome

Outcomes:
-full recovery
-sporadic psychotic episodes with no inter-episode impairment
-sporadic psychotics episodes with persistent but mild cognitive and negative symptoms
-sporadic psychotic episodes with severe functional disability between episodes
-frequent psychotic episodes with severe functional disability between episodes
-no psychotic symptoms after first episode but severe functional disability
-continuous psychotic symptoms with severe functional disability
-continuous psychotic symptoms with complete functional disability
-in general, outcome determined more by circumstances under which illness develops and by premorbid personality than by positive symptoms of illness

Males have more hospitalizations and longer stays than women

Prodromal phase less than or equal to 5 years
-subclinical or attenuated symptoms
-ex: disruptions in sleep, anxiety, depression, aggression/irritability, paranoia, and odd beliefs

Initial emergence of symptoms (first episode) is a critical time for treatment
-widely believed that the earlier antipsychotic medications are initiated, the better the outcome

-Deterioration most pronounced during first 5 years of illness
-Evidence that each relapse leads to more persistent symptoms and greater cognitive and psychosocial impairment
-effective and early intervention does help achieve clinical remission and good outcome
A. [Criterion A or active phase] At least two of the following, each present for a significant portion of time during a 1 month period (or less if successfully treated). At least one of these must be (1), (2), or (3):
1. delusions
2. hallucinations
3. disorganized speech (ex: frequent derailment or incoherence)
4. grossly disorganized or catatonic behavior
5. negative symptoms (ex: diminished emotional expression or avolition)

B. For a significant portion of time since the onset of the disturbance, level of functioning in one or more major areas (work, interpersonal relations, self-care) is markedly below the level achieved prior to the onset
-or when the onset is in childhood or adolescence, there is failure to achieve expected level of interpersonal, academic, or occupational functioning

C. Continuous signs of the disturbance persist for at least 6 months
-must include at least 1 month of symptoms that meet Criterion A (active phase symptoms)
-may include periods of prodromal or residual symptoms
during prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or by two or more symptoms listed in Criterion A present in a lesser form

D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either:
1. no major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or
2. if mood episodes have occurred during active phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness

E. The disturbance is not attributable to the physiological effects of a substance or another medical condition
-ex: a drug of abuse, a medication

F. If there is a history of autism spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations
-in addition to the other required symptoms of schizophrenia
Tardive Dyskinesia
-abnormal, involuntary movements (twitching, snake-like, writhing) involving the tongue, lips, jaw, face, extremities, and occasionally the trunk
-symptoms may persist indefinitely after discontinuation of medication
-Rx: prevention-limit exposure to antipsychotic drugs

Parkinsonian Symptoms:
-triad of signs --> tremor, rigidity and slowed movement
-"cogwheel" feel
-Rx: artane, cogentin, benadryl

Akathisia:
-compulsion to be in motion
-need to be in motion rather than any specific movement
-Rx: lower dose of antipsychotic drug

Acute dystonic reactions:
-impaired or disordered muscle tone
-include acute dyskinesias (abnormal involuntary movements of various types)
-involuntary muscle contractions particularly around the mouth, jaw, face and neck
-Rx: benzodiazspines (ex: Valium); antihistamine drugs (ex: Benadryl); anticholinergic antiparkinson drug (ex: Cogentin)

Sedation
-tolerance tends to develop over a period of days or weeks

Seizures
-for most seldom a problem
-occasionally individuals with a history of seizures may experience a seizure during treatment
-increased in clozapine

Neuroleptic Malignant Syndrome:
-fever, muscular rigidity, stupor
-also autonomic dysfunction (increased pulse, respirations, and sweating)
-Rx: discontinue antipsychotic drug immediately

Anticholinergic Effects:
-peripheral (warmth, flushing, dryness, dilated pupils, difficulty with visual accommodation, increased intraocular pressure, dry mouth, increased heart rate, constipation, delayed urination, delayed or retrograde ejaculation)
-CNS (memory difficulties, confusion, and, in extreme situation, delusion)
-Serious toxicity (confusion, disorientation, agitation, large pupils, dry mucous membranes, hot and flushed skin, tachycardia)

-cardiovascular effects
-skin reactions
-neuroendocrine effects
-other reactions: jaundice, blood disorders

Overdose:
-rarely a problem with antipsychotic drug alone because of their high therapeutic index

Drug interactions:
-potentiate the action of CNS depressants (ex: alcohol)
A: a distinct period of abnormally and persistently elevated, expansive, or irritable mood, and abnormally and persistently increased goal-directed activity or energy
-needs to last AT LEAST 1 week, and present more of the day, nearly every day

B: during the period of mood disturbance and increased energy or activity, must have at least 3 of the following symptoms (4 if the mood only irritable), present to a significant degree and represent a noticeable change from usual behavior
-inflated self-esteem or grandiosity
-decreased need for sleep (e.g. feels rested after only 3 hours of sleep)
-more talkative than usual or pressure to keep talking
-flight of ideas of subjective experience that thoughts are racing
-distractibility (i.e. attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed
-increase in goal-directed activity (either socially, at work, school or sexually), or psychomotor agitation (purposelessness non-goal directed activity)
-excessive involvement in activities that have a high potential for painful consequences (engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

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

D. not attributable to the physiological effects of a substance or to another medical condition
-Note: a full manic episode that emerges during antidepressant treatment but persists at a fully syndromal level beyond physiological effect of that treatment is a bipolar I diagnosis

Note: Criteria A-D constitute a manic episode
-at least 1 manic episode is required for diagnosis of bipolar 1
A. a distinct period of abnormally and persistently elevated, expansive or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days

B. 3 (or more) of the following symptoms (4 if the mood is only irritable)
-inflated self-esteem or grandiosity
-decreased need for sleep (e.g. feels rested after only 3 hours of sleep)
-more talkative than usual or pressure to keep talking
-flight of ideas of subjective experience that thoughts are racing
-distractibility (i.e. attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed
-increase in goal-directed activity (either socially, at work, school or sexually), or psychomotor agitation (purposelessness non-goal directed activity)
-excessive involvement in activities that have a high potential for painful consequences (engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

C. episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic

D. disturbance in mood and the change in functioning are observable by others

E. the episode is NOT severe enough to cause marked impairment in social/occupational functioning or to necessitate hospitalization
-if psychotic features, it is by definition, manic

F. not attributable to the physiological effects of a substance or another medical condition

Note: Criteria A-F constitute a hypomanic episode, common in bipolar I disorder but are not required for the diagnosis of bipolar I
-consolidates dysthymic disorder and chronic major depressive disorder (criteria ~ dysthymic disorder)

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

B. Presence, while depressed, of at least 2 of the following:
-poor appetite or overeating
-insomnia or hypersomnia
-low energy or fatigue
-low self-esteem
-poor concentration or difficulty making decisions
-feelings of hopelessness

C. During the 2-year period, the individual has never been without 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. Never been a manic or hypomanic episode, and criteria have never been met for cyclothymic disorder

F. ...not better explained by...


Specify if (for most recent 2 years):

-with pure dysthymic syndrome: full criteria for a major depressive episode have not been met in at least the preceding 2 years

-with persistent major depressive episode: full criteria for a major depressive episode have been met throughout the preceding 2-year period

-with intermittent major depressive episodes, with current episode: 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: 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
Note: must be older than 6 years old

A. Exposure to actual or threatened death, serious injury, or sexual violence in 1 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 a close family member/close friend. In cases of actual or threatened death of a family member/friend, the event(s) must have been violent or accidental
4) experiencing repeated or extreme exposure to aversive details of the traumatic event(s)
-ex: first responders collecting human remains, constant exposure to child abuse)
-note: does not apply to exposure though electronic media

B. presence of 1 or more of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event:
1) recurrent, involuntary and intrusive distressing memories of the traumatic event
2) recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event
3) dissociative reactions (flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring
4) intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
5) marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event

C. persistent avoidance of stimuli associated with the traumatic event, as evidenced by 1 or both of the following:
-avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event
-avoidance of or efforts to avoid external reminders that arouse distressing memories, thoughts or feelings about or closely associated with the traumatic event

D. negative alterations in cognitions, and mood
-persistent, distorted cognitions about the cause or consequences of the traumatic events that lead the individual to blame self or others
-persistent negative emotional state
-markedly diminished interest or participation in significant activities
-feelings of detachment or estrangement from others
-persistent inability to experience positive emotions

E. marked alterations in arousal and reactivity associated with the traumatic event, as evidenced by 2 or more of the following:
1) irritable behavior and angry outbursts
2) reckless or self-destructive behaviors
3) hyper-vigilance
4) exaggerated startled response
5) problems with concentration
6) sleep disturbance

F. Duration of the disturbance (C and C and D and E) is more than 1 month

G. ...clinically significant....

H. ...not attributable...

Specify whether:
-with dissociative symptoms (persistent or recurrent symptoms of depersonalization or derealization)

Specify if:
-with delayed expression (if full diagnostic criteria are not met until at least 6 months after the event)

Note more symptoms required for diagnosis of ASD(9) than PTSD(6)
-alcohol
-caffeine
-cannabis
-phencyclidine
-hallucinogen
-inhalant
-opioid
-sedative, hypnotic, or anxiolytic
-stimulant
-tobaccos
-other

A. a problematic pattern of...use leading to clinically significant impairment or distress, as manifested by at least 2 of the following, occurring within a 12-month period:
1) ...is often taken in larger amounts or over a longer period than was intended
2) there is a persistent desire or unsuccessful efforts to cut down or control...use
3) a great deal of time is spent in activities necessary to obtain..use...or recover from its effects
4) craving, or a strong desire or urge to use...
5) recurrent...use resulting in a failure to fulfill major role obligations at work/school/home
6) continued...use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of...
7) important social, occupational, or recreational activities are given up or reduced because of...
8) recurrent...use in situations in which it is physically hazardous
9) ...use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been cause or exacerbated by...
10) tolerance, as defined by either of the following:
-a need for markedly increased amounts of...to achieve intoxication or desired effect
-a markedly diminished effect with continued us of the same amount...
11) withdrawal, as manifested by either of the following:
-the characteristic withdrawal syndrome for...(refer to criteria A and B of the criteria set for...withdrawal)
-...(or a closely related substance) is taken to relieve or avoid withdrawal symptoms

Overall areas of concern:
-impaired control (symptoms 1-4)
-social impairment (5-7)
-risky use (8-9)
-pharmacological (10-11)

Specify severity
-mild (2-3 symptoms)
-moderate (4-5 symptoms)
-severe (greater than 6 symptoms)

Specify if:
-with physiological dependence
-without physiological dependence

Course Specifiers:
-in early remission
-in sustained remission
-on maintenance therapy
-in a controlled environment