15 - 51_Classification

01 - 1. Approaches to Classification

1. Approaches to Classification

© SPMM Course

  1. Approaches to Classification The two major contemporary classificatory systems are ICD 10 (1992) and DSM IV (1994). American Psychiatric Association produces the DSM system. WHO commissioned ICD 10? DSM-V was released in 2013 but there has been much criticism of this system, and as of yet it has not been adopted widely except by clinicians communicating with insurers in the USA. It is anticipated that ICD11 will be released in 2017 Both classificatory systems are categorical systems of classification based on clinical descriptions. While both ICD-10 and DSM-4 are diagnostic and classificatory systems and are meant to provide reliable diagnosis, they do not provide assessment plans, case formulations or treatment plans. Various terms are used to describe the characters of classificatory systems. The concept of operationalized criteria, atheoretical approach, hierarchical organisation and multi-axial classification are important for MRCPsych Paper A exam and are described below. Operationalised approach: In DSM-III operationalised diagnosis was first introduced. Operational criteria include the use of precise clinical description of disorders, together with predefined exclusion and inclusion criteria and details of the number and duration of symptoms required for diagnosis. It enables algorithm-based clinical diagnosis using intensity, duration of the symptoms and impairment tests. This more or less equates to using a checklist for diagnosis, but some rules are necessary while some are optional for a diagnosis. Characteristic symptoms are pertinent to the diagnosis, such as the symptom of depression, which is found in many different disorders. Discriminating symptoms, e.g. thought insertion, are necessary for diagnosis since they are not found in other diseases. Pathognomonic symptoms, if present, strongly favour one diagnosis over another. Thus, they are more specific to a condition than other symptoms (e.g. flashbacks of trauma and PTSD). Inclusion and exclusion criteria: A hierarchy of symptoms, arranged in order of importance (e.g. criterion A and B etc.) often accompanies diagnostic descriptions in operationalised systems. These form the core inclusion and exclusion criteria used in practice to establish a diagnosis. Computerised scoring systems such as OPCRIT (for ICD10) facilitate the application of such operationalised diagnoses. The atheoretical approach means diseases are described according to the observed phenomenology; classification is NOT based on the understanding of what might be causing the disturbances. So various aetiological schools such as behaviourism or psychoanalysis, etc. are not employed in describing a disorder. No theory forms the basis of the classifications; only neutral observations are taken into account. The descriptive approach refers to classifying illnesses on the basis of what constitutes the illness rather than what causes it; Lack of pathogenetic knowledge of most psychiatric disorders makes this approach more rational. This forms the basis of any atheoretical classification.

© SPMM Course Categorical vs. dimensional approaches: The current classificatory systems entertain categorical diagnoses only; i.e. similar to medical diseases. In other words using current systems, we can only say whether  an  individual’s  clinical  presentation  either  meets  or  does  not  meet  the  diagnostic  criteria  for  a   particular disorder. A patient either has or does not have pneumonia; she has or does not have schizophrenia, etc. Contrast this approach with measurement of blood pressure – we use a continuum from low to high along which measurement is made. (It only becomes categorical when we apply the label “hypertension”  to  indicate  that  a  patient  has  clinically  troublesome  problem  with  high  BP).  Of all psychiatric disorders, the need to develop a dimensional system for description is said to be more urgent for personality disorders. Categorical approach Dimensional approach Traditionally doctors are accustomed to thinking in terms of categories – easy to understand. All existing knowledge base about the presentation, aetiology, epidemiology, course, prognosis, and treatment is based on these categories. Categories are easy to communicate with professionals Poor validity –vague  categories  such  as  ‘Psychosis  - not  specified’  are  needed  to  include  atypical   cases.

More valid as most emotional and cognitive states exist as a continuum without clear cut-off point between ill and the well. Severity can be better indicated Need to entertain many comorbid diagnoses may be prevented. Research studies using dimensional scales as end points have much greater power to detect differences in groups than do studies focusing on changes in dichotomous categories Clinical utility is questionable, as dimensions cannot be directly mapped onto clinical decisions such as starting or stopping an intervention. Hierarchical organisation is largely abandoned in DSM and somewhat maintained in ICD-10 in its organisation of chapters. Hierarchy means that certain disorders take precedence over others while making a diagnosis. This follows Jasperian ideas (Karl Jaspers: see Introduction to Psychopathology for more details) – the ladder starts from organic disorders through to substance use issues, psychosis, affective and neurosis up to personality issues. If a disorder on top of the hierarchy can explain the observed symptoms, then a diagnosis should not be entertained from down below the hierarchy even if the constellation of symptoms are suggestive of such a diagnosis. To understand the concepts of hierarchy consider the following example. Dementia and other brain-based organic disorders can be associated with any type of psychiatric problem. But a separate diagnostic label is not used for each of these  psychiatric  syndromes.  For  example,  ‘schizophrenic  symptoms’  occurring  in  the  course  of   Huntington’s  disease  or  temporal  lobe epilepsy or severe learning disability do not change the diagnosis  to  ‘schizophrenia’  in  these  cases.  Other examples include the co-occurrence of depression and agoraphobia, depression and OCD, organic delirium and psychosis – in all these cases the first diagnosis is primarily entertained instead of the second even if the symptoms could be explained by

02 - Structure of ICD 10

Structure of ICD-10

© SPMM Course both diagnoses in a given patient at a point of time. This hierarchy is generally non-reflexive, i.e. each disorder tends to manifest the symptoms of those lower down but not those of disorders higher up. Despite such a hierarchical construct, co-morbidity can be still entertained, and this is explicitly encouraged when using DSM. For example, alcohol used disorder can be comorbid with depressive disorder. Multi-axial approach: Recently there has been an upsurge of interest in the multi-axial system for achieving a complete diagnosis.  This  method  helps  in  a  more  ‘holistic  assessment’ of an individual patient. o The multi-axial version of ICD-10 uses three axes. Axis 1 - the mental disorder (also personality disorder and mental handicap); Axis 2 - the degree of disability; and Axis 3 - current psychosocial problems. o The multi-axial system of DSM uses 5 axes. Axis I - Clinical Disorders; Axis II - Personality Disorders/ Mental Retardation; Axis III - General Medical Conditions; Axis IV - Psychosocial and Environmental Problems; Axis V - Global Assessment of Functioning. Note that child and adolescent mental disorders have a different axial system in DSM-IV. Structure of ICD-10 The first ICD in 1855 was concerned with a nomenclature of causes of death. World Health Organization (WHO) in 1948 adopted this version after many revisions and called ISCD 6 - Sixth Revision of the International Statistical Classification of Diseases, Injuries and Causes of Death. The ICD-10 is a general medical classification system intended for worldwide, multi-specialty use. ICD-10 classification is easy to follow and has been tested extensively all over the world in more than 51 countries and has been found to be generally applicable. ICD-10 includes 21 chapters. The Roman numeral V and the letter F denote the position of mental and behavioural disorders as the fifth chapter in the WHO classification as a whole. The disorders are identified using an open alpha-numeric system in the form Fxx.xx  from  F00  to  F99.  The  letter  ‘F’  identifies   the disorder as a mental or behavioural disorder; the first digit refers to the broad diagnostic grouping (e.g. psychotic, organic etc.); and the second digit refers to the individual diagnosis. The digits, which follow the decimal point, the code for additional information specific to the disorder such as sub-type, course, or type of symptoms. For example, F33.10 refers to recurrent depressive disorder, current episode moderate with the somatic syndrome. The Schedule for Clinical Assessment in Neuropsychiatry (SCAN), the Composite International Diagnostic Interview (CIDI), and the International Personality Disorder Examination (IPDE) are assessment instrument developed based on the ICD-10framework. Four versions of the ICD-10 classification of mental disorders exist, suitable for different purposes.

03 - Structure of DSM IV

Structure of DSM-IV

04 - Newer Classification Systems

Newer Classification Systems

05 - Proposed changes to ICD 11

Proposed changes to ICD-11

© SPMM Course o ICD-10: CDDG (clinical descriptions and diagnostic guidelines) - for clinical, educational and service use. It is mainly used by psychiatric practitioners and gives clinical descriptions of each disorder together with the diagnostic criteria. o ICD-10: DCR (diagnostic criteria for research) contains more restrictive and clearly defined clinical features with explicit inclusion, exclusion, and time-course criteria, and is suitable for identification of homogeneous patient groups for research purposes. o ICD-10: Primary care version - focuses on those disorders prevalent in primary care settings and contains broad clinical descriptions, diagnostic flowcharts, and treatment recommendations. o ICD 10: Clinical Coding Manual - Short glossary containing the coding together with brief descriptions can be used as a quick reference by practitioners, as well as by administrative and secretarial staff. It is suitable for clerical workers and for coding purposes. Structure of DSM-IV While ICD-10 is a wider general medical classification, DSM-IV describes only mental disorders. DSM-IV uses a closed, numeric coding system of the form xxx.xx. A single version of DSM-IV is used for both clinical and research purposes. DSM takes a descriptive approach, and the characteristic signs and symptoms of each disorder should be present before a diagnosis is made. It is neutral and atheoretical regarding the causes of mental disorders and does not subscribe to any models of causation of disorders such as cognitive theories, learning theories, etc. Its diagnoses are non-hierarchical, which implies that more than one diagnosis can be made. An important step included in the development of DSM-IV was the attempt to strengthen the reliability of classification. The inter-rater agreement for Axis 1 disorders is very high (0.73 and 1.00) and has repeatedly demonstrated greater diagnostic stability over time.

Newer Classification Systems Proposed changes to ICD-11 ICD-11 is under preparation and consultation now and is expected to be released by 2017. Some of the significant changes expected in ICD-11 are highlighted below. Note that these are subject to updates and revisions. x Presumed aetiological groupings rather than conventional symptom-based groupings employed for placing each disorder in a chapter x Neurodevelopmental disorders will be set in chapter 1 x Bipolar disorders will be split from depressive disorders and placed in a separate chapter x Dissociative disorders will be split from stress-induced disorders x OCD will be separated from anxiety disorders x Factitious disorders will be placed in a separate chapter x Conditions related to substance use will be split into various chapters x No restriction in number of character places when coding the disorders

06 - Summary of major changes to DSM 5

Summary of major changes to DSM-5

© SPMM Course Summary of major changes to DSM-5 DSM-5 is comprised of three sections: Section 1: An introduction and guidance to use; Section 2: An outline of the diagnostic categories with the newly revised chapters; Section 3: Includes a list of conditions that require further research before their consideration as formal disorders. It also includes details on cultural formulations. A multiaxial system that separately identified personality disorders (Axis II) and medical conditions (Axis III) has been modified. The new multiaxial system now includes only three axes - psychiatric disorder, psychosocial and environmental factors associated with them, and the severity of associated disability. In effect, this means personality disorders are treated with the same importance as other psychiatric disorders. This has moved DSM’s  multiaxial  system  closer  to  ICD’s  multiaxial  system. A brief note on other major changes is given below. Further details are provided downstream when discussing the major disorders.

•Removal of 'bizarre' delusions •Removal of subtypes of schizophrenia •3 core symptoms recognised (delusions, hallucinations and disorganised speech) •Changes in schizoaffective criteria Psychosis Psychosis •Dysthymia & chronic depression merged •Bereavement no longer an exclsuion for depression •Premenstrual dysphoric disorder is a new diagnostic entity

Mood disorder Mood disorder •Asperger's syndrome removed and merged with autism as ASD •ADHD age criteria relaxed Developmental disorders Developmental disorders •Anorexia diagnosis does not require amennorhea •Bingeing frequency required to diagnose bulimia relaxed •OCD and PTSD moved out of Anxiety Disorders to separate chapters •New labels: Hoarding Disorder, Excoriation Disorder, DMDD - Disruptive Mood Dysregulation Disorder introduced Other changes Other changes

07 - 2. Psychoactive substance use disorders

2. Psychoactive substance use disorders

© SPMM Course 2. Psychoactive substance use disorders

Mental and behavioural disorders due to psychoactive substance use are dealt in Chapters F10 to F19 in ICD-10. Substances discussed here include alcohol, opioids, cannabinoids, sedatives, cocaine, other stimulants including caffeine, hallucinogens, tobacco, solvents and the use of multiple substances. Various clinical syndromes associated with the use of substances are described:

Syndromes Subdivisions Acute intoxication Transient disturbances in the level of consciousness, cognition, perception, affect or behaviour, or other psychophysiological functions and responses. Usually related to dose/levels of consumed substance Symptoms need not always in accord with the expected physiological properties of the drug (e.g. a depressant can cause agitation). Harmful use A pattern of substance use that is causing damage to physical or mental health. Should not be diagnosed if dependence syndrome or substance-induced psychosis are diagnosed. Dependence Cognitive and behavioural phenomena indicating that the use of The substance takes on a much higher priority for a given individual than other previously salient behaviours. A checklist of features is described to diagnose each dependence syndrome (also see Edward & Gross criteria given below). Withdrawal state The syndrome occurs on absolute or relative withdrawal of a substance after repeated and prolonged use. Withdrawal Delirium Withdrawal accompanied by confusional state Psychotic disorder Psychotic phenomena that occur during or immediately after psychoactive substance use (esp. auditory hallucinations and paranoid delusions) Amnesic syndrome Chronic impairment of recent memory with relatively preserved remote memory and immediate recall. Late-onset disorders Changes in cognition, emotion and personality or behaviour that persist beyond the period of expected physiological effects of the consumed substance.

ICD10  has  a  diagnostic  code  for  ‘harmful  use’ where the actual damage is caused to the drinker physically or mentally, but he has no dependence pattern (yet). In contrast, DSM-IV upholds the concept  of  ‘abuse’ which refers to maladaptive use

  1. Despite problems in social, occupational, physical and psychological domains
  2. In hazardous situations
  3. At least one month, recurring over a longer period usually.
  4. But not dependent on alcohol.

©"SPMM"Course" 8" ! ICD10"alcohol"dependence"requires"at"least"3"out"of"following"list"satisfied"in"last"12"months:"

  1. Intense"desire"to"drink"alcohol"
  2. Difficulty"in"controlling"the"onset,"termination"and"the"level"of"drinking"
  3. Experiencing"withdrawal"symptoms"if"alcohol"is"not"taken"
  4. Use"of"alcohol"to"relieve"from"withdrawal"symptoms"
  5. Tolerance"as"evidenced"by"the"need"to"escalate"dose"over"time"to"achieve"same"effect"
  6. Salience"–"neglecting"alternate"forms"of"leisure"or"pleasure"in"life"
  7. The"narrowing"personal"repertoire"of"alcohol"use." ! DSMDIV"alcohol"dependence"requires"at"least"3"out"of"following"list"lasting"for"at"least"a"month:"
  8. Consuming"alcohol"for"longer"period"and"in"larger"amounts"than"intended"
  9. Unsuccessful"attempts"to"cut"down"
  10. Experiencing"withdrawal"symptoms"if"alcohol"is"not"taken"
  11. use"of"alcohol"to"relieve"from"withdrawal"symptoms"
  12. Tolerance"as"evidenced"by"the"need"to"escalate"dose"over"time"to"achieve"same"effect" (at"least"50%"increase"from"start)"
  13. Salience"–"most"time"of"life"spent"on"pursuing"alcohol"directly"or"indirectly"
  14. Failure"in"role"obligations"and"physical"health"
  15. Giving"up"alternate"pleasures"
  16. Continued"use"despite"knowing"the"harm"caused" " ! " " " " " " " " " Edwards"&"Gross"criteria"(1976)"for"dependencem • Narrowed"repertoirem • Salience"of"alcohol"seeking"behaviour

• Increased"tolerance

• Repeated"withdrawals

• Drinking"to"prevent"or"relieve"withdrawals.

• Subjective"awareness"of"compulsion

• Reinstatement"after"abstinence

08 - 3. Organic disorders

3. Organic disorders

© SPMM Course 3. Organic disorders

Chapter F00 in ICD-10 discusses organic disorders such as dementia. Major categories include dementia  of  Alzheimer’s  disease,  vascular  dementia,   dementia in other diseases classified elsewhere (includes  CJD,  Parkinson’s  dementia  etc.),  organic amnesic syndromes, delirium, other mental disorders due to brain damage (includes organic hallucinosis, catatonic disorder, mild cognitive disorder etc.) and personality change due to brain damage. Depressive pseudodementia: This is not a separate diagnostic entity, but a descriptive term often used in old age psychiatry. Depression in elderly patients may present as dementia clinically. This is called depressive pseudodementia. Here the patient complain of memory impairment, difficulty in sustaining attention and concentration and reduced intellectual capacity. Major clinical features differentiating pseudo-dementia from dementia are tabulated below Pseudodementia Dementia Onset can often be dated precisely Onset can be dated only within broad limits Symptoms usually of short duration before seeking help Symptoms usually of long duration before medical help is sought Rapid progression of symptoms after onset Slow progression of symptoms throughout course Patients complain actively of the cognitive impairment Patients often complain little of their cognitive difficulties (may even conceal disability and appear unconcerned) Nocturnal accentuation of dysfunction uncommon Nocturnal accentuation of dysfunction common Attention and concentration often well preserved Attention and concentration usually faulty On  direct  testing  ‘Don'ʹt  know’  answers  are  typical  (the   patient is not trying hard) Near-miss answers are frequent in cognitive tests (the patient is trying but not efficient) Memory loss for remote events may be more severe than for recent ones Memory loss for current events usually more severe than for remote events (Adapted from Kaplan & Sadock - Synopsis of psychiatry-10th edition) Dementia  in  Alzheimer’s  disease  (diagnostic  criteria) x Global deterioration in intellectual capacity and disturbance in higher cortical functions like memory, thinking, orientation, comprehension, calculation, language, learning DSM-5 AND CATATONIA Presence of three catatonic symptoms from a total of 12 is required to diagnose catatonia. In DSM-5, catatonia may be diagnosed as a specifier for depressive, bipolar, and psychotic disorders; as a separate diagnosis in the context of another medical condition; or as another specified diagnosis.

© SPMM Course abilities and judgement, an appreciable decline in intellectual functioning and some interference with personal activities of daily living. x Insidious onset with slow deterioration x The absence of clinical evidence or findings from individual investigations suggestive of organic brain disease or other systemic abnormalities. x Absence of sudden onset or physical/neurological signs Remember 5As x Amnesia-Impaired ability to learn new information and to recall previously learned information x Aphasia-Problems with language (receptive and expressive) x Agnosia-Failure of recognition, especially people x Apraxia-Inability to carry out purposeful movements, even though, there is no sensory or motor impairment x Associated disturbance-behavioural changes, delusions, hallucinations Some patients exhibit mild cognitive impairment before the onset of full-blown dementia. A significant proportion of those with MCI does not develop dementia: if they convert to dementia, the most common dementia to develop is Alzheimer’s  dementia. Vascular dementia x Presence of a dementia syndrome, defined by cognitive decline from a previously higher level of functioning and manifested by impairment of memory and of two or more cognitive domains (orientation, attention, language, Visuospatial functions, executive functions, motor control and praxis) and deficits should be severe enough to interfere with activities of daily living not due to physical effects of stroke alone. (NINDS AIREN criteria) x Onset may usually follow a cerebrovascular event and is more acute x The course is usually stepwise, with periods of intervening stability. x Focal neurological signs & symptoms or neurological evidence of cerebrovascular disease (CVD) judged etiologically related to the disturbance. CVD defined by the presence of focal signs on neurological examination, such as hemiparesis, lower facial weakness, Babinski sign, sensory deficit, hemianopia and dysarthria and evidence of relevant CVD by brain imaging (CT or MRI) x Emotional and personality changes are typically early, followed by cognitive deficits that are often fluctuating in severity.

© SPMM Course x Symptoms are not occurring during the course of the delirium Dementia with Lewy Bodies x Spontaneous motor features of Parkinsonism x Fluctuating cognition with notable variation in attention + alertness x Recurrent visual hallucinations, which are typically well formed and detailed. x A progressive cognitive decline that is severe enough to interfere with normal social and occupational functioning and memory loss may not be an early feature, but it is usually evident with progression. x Supportive features: Neuroleptic sensitivity and history of falls Parkinson’s  disease  dementia: If the Parkinsonian symptoms have existed for more than 12 months  before  dementia  develops  then  a  diagnosis  of  Parkinson’s  disease  dementia  is given. If both motor symptoms and cognitive symptoms develop within 12 months, then it is conventional to give a diagnosis of Lewy body dementia. Frontotemporal dementia x Insidious onset and gradual progression x Early loss of personal and social awareness x Early emotional blunting, Early loss of insight x Behavioural features: Early signs of disinhibition, decline in personal hygiene & grooming, mental rigidity, inflexibility, hyperorality, stereotyped and perseverative behaviour x Speech disorder: Reduced output + signs such as stereotypy, echolalia, and perseveration x Affective symptoms: Anxiety, depression, and frequent mood changes, emotional indifference. x Physical signs: Incontinence, primitive reflexes, akinesia, rigidity and tremor. Notable features in other organic disorders x Most cases of delirium recover in 4 weeks; in chronic lung disease, subacute bacterial endocarditis and carcinoma delirium may last up to 6 months. x In organic hallucinosis, insight may be present. x Encephalitis and CO poisoning can cause organic catatonia. x Influenza can cause post-infective depression.

09 - 4. Classification of psychosis

4. Classification of psychosis

10 - Schizophrenia

Schizophrenia

11 - Earlier diagnostic criteria

Earlier diagnostic criteria

© SPMM Course 4. Classification of psychosis Schizophrenia Schizophrenia usually manifests as a severe psychotic illness with onset in early childhood, characterised by bizarre (i.e. Schneiderian) delusions, auditory hallucinations, thought disorder, strange behaviour and progressive deterioration in personal, domestic, social and occupational functioning, all occurring in clear consciousness. Common symptoms: The International Pilot Study of Schizophrenia survey determined the commonest symptoms exhibited by 306 acute schizophrenia patients in 9 countries as follows: Lack of insight – 97% Auditory hallucinations - 74% Ideas of reference – 70% Suspiciousness – 66% Flatness of affect – 66% Second person hallucinations – 65% Delusional mood – 64% Delusions of persecution – 64% Thought alienation – 52% Echo De Pensee, Gedankenlautwerden- 50% Earlier diagnostic criteria Before DSM-IV and ICD-10, various criteria were put forward to diagnose schizophrenia. Some of these are MRCPsych favourites: St Louis or Feighner criteria (Feighner et al. 1972) or Washington University Criteria National Institute of Mental Health (NIMH) Research Diagnostic Criteria (RDC) predating DSM-III For a diagnosis of schizophrenia, A through C are required: A. Both of the following are necessary: o A chronic illness with at least six months of symptoms prior to the index evaluation without a return to the premorbid level of psychosocial adjustment. o The absence of a period of depressive or manic symptoms sufficient to qualify for affective disorder or probable affective disorder. B. The patient must have at least one of the following: o Delusions or hallucinations without significant perplexity or disorientation associated with them. o Verbal production that makes communication difficult because of a lack of logical or understandable organization. (In the presence of muteness the diagnostic decision must be deferred.) C. At least three of the following manifestations must be present for a diagnosis of "definite" schizophrenia, and two for a diagnosis of "probable" schizophrenia. o Single o Poor premorbid social adjustment or work history o Family history of schizophrenia o Absence of alcoholism or drug abuse within one year Includes a polythetic symptom criterion, a duration criterion and an exclusion criterion.

The symptom criterion lists eight symptoms or groups of symptoms. The first seven symptom groups are Schneiderian first-rank symptoms and other delusions or hallucinations, the last one gives diagnostic value to formal thought disorder if accompanied by either blunted or inappropriate affect, delusions or hallucinations of any type or grossly disorganized behaviour.

The duration criterion requires that signs of the illness have lasted at least 2 weeks from the onset of a noticeable change in the  subject’s  usual  condition.

The exclusion criterion describes the differential diagnosis with affective disorders: at no time during the active period of illness being considered did the subject meet the full criteria for either probable or definite manic or depressive syndrome to such a degree that it was a prominent part of the illness.

12 - ICD 10 schizophrenia

ICD-10 schizophrenia

© SPMM Course of onset of psychosis o Onset of illness prior to age 40

ICD-10 schizophrenia ICD 10 description of schizophrenia is largely based on Schneider’s  first-rank symptoms. Kurt Schneider described a number of symptoms which he believed were of first-rank importance in differentiating schizophrenia from related illnesses. According to the International Pilot Study of Schizophrenia, 58% of patients with acute schizophrenia exhibited at least one first rank symptom. However, at least 20% of schizophrenic never exhibit a first rank symptom while almost 10% of non-schizophrenic patients exhibit them. Duration criteria in ICD: ICD10 rejects the assumption that schizophrenia is an illness of necessarily long duration. Accordingly, acute psychotic episodes are diagnosed for up to one month; if schizophrenic features are continuous, the diagnosis is reclassified as schizophrenia after a month. If not, a diagnosis of the acute psychotic episode is valid for up to 3 months, after which other diagnoses such as a persistent delusional disorder may be entertained. Prodromal symptoms of schizophrenia are not included in the 1-month criteria for schizophrenia. Subtypes of schizophrenia Subtype Most prominent symptoms Less prominent (may or may not be present) Paranoid (commonest, with onset usually at a later age compared to hebephrenia and catatonia) Delusions or auditory hallucinations

Disorganized speech or behaviour Flat or inappropriate affect Catatonic behaviour Hebephrenic or disorganised (poorest prognosis) Disorganized speech or behaviour and flat or inappropriate affect. Markedly impaired social and occupational functioning; poor self-care, poor hygiene, extreme social behaviour and disorganised behaviour Catatonic behaviour

Catatonic (more common in developing nations; usually acute onset with episodic course and complete symptom remission) x Motoric immobility (i.e., catalepsy or stupor) x Excessive motor activity x Extreme negativism or mutism x Posturing, or stereotypy, mannerisms, grimacing x Echolalia or echopraxia (Minimum 2 of the above needed) Oneiroid (dream like) state can occur, and patients may experience visual hallucination. Transient catatonic features can be seen in all schizophrenia types

© SPMM Course Residual Evidence of full blown acute episode in the past Currently negative symptoms or attenuated forms of 2 or more generic symptoms (i.e. odd beliefs instead of delusions, unusual perceptual experience instead of fully formed hallucinations) Absence of delusions, hallucinations, disorganized speech or behaviour, catatonia

Simple Insidious development of negative symptoms without evidence of positive symptoms.  Very  rare.  Appears  as  if  one’s  personality  is  gradually  deteriorating   with increasing emotional bluntness; Occasional brief psychotic episodes may support the diagnosis. Undifferentiated Generic symptoms but not falling in other categories ‘Chronic  schizophrenia.' Persistent disability for two years or longer (not a subtype but a descriptive term)

Catatonic schizophrenia is characterised by marked disturbance of motor behaviour and can present in three clinical forms; (1) excited catatonia (2) stuporous catatonia and (3) catatonia alternating between excitement and stupor. Hebephrenic schizophrenia is characterised by marked thought disorder and severe loosening of associations, emotional disturbances described by inappropriate affect, blunted affect or senseless giggling, abnormal mannerisms like mirror gazing. ICD 10 recommends a period of 2-3 months of continuous observation for a confident diagnosis. Hypochondriacal complaints may be seen in some cases. Philosophical, religious and abstract preoccupations may be seen along with a preference for solitariness. The onset of hebephrenic schizophrenia is insidious, usually in the early second decade (15 to 25 years). The course in many patients is relentlessly downhill. Severe deterioration without remissions often occurs over time. The recovery from the episode classically never occurs. The term ‘disorganised schizophrenia’ is used to denote hebephrenia in DSM-IV. Simple schizophrenia is characterised by an early onset (usually in the second decade), very insidious and progressive course, and presence of characteristic negative symptoms like marked social withdrawal, loss of initiative and drive or shallow emotional response. People with this condition drift down the social ladder quickly, living shabbily and wandering aimlessly. Delusions and hallucinations are usually absent if present they are short lasting and poorly systematised. The prognosis is usually very poor. Note that for simple schizophrenia – duration criteria is one year, not one month (ICD-10). Residual schizophrenia consists of long-term but not necessarily irreversible negative symptoms. Delusions and hallucinations must have been minimally intense or reduced for at least one year period. The positive symptoms are gradually replaced by negative symptoms. According to the ICD 10 diagnosis “residual schizophrenia is characterised by the following features in additional to the general guidelines of schizophrenia which includes prominent negative schizophrenic symptoms, evidence in the past of at least one clear-cut psychotic episode meeting the diagnostic criteria for schizophrenia, a period of at least one year during which the intensity and frequency of

13 - Contrasting DSM IV and ICD 10

Contrasting DSM-IV and ICD-10

© SPMM Course florid symptoms such as delusions and hallucinations have been minimal or substantially reduced and absence of organic brain disease or disorder”. Post schizophrenic depression is classed under F20s. Some schizophrenic symptoms (mostly negative) must be present though not dominating the picture. The most recent episode of relapse must not be more than 12 months ago. If no current schizophrenic symptoms at all then depressive disorder can be diagnosed. If florid schizophrenia symptoms with minor affective disturbances noted, then relapse must be suspected. Contrasting DSM-IV and ICD-10

ICD 10 DSM IV Characteristic symptoms

At least one of:

  1. Thought echo, thought insertion/withdrawal/broadcast
  2. Passivity, delusional perception
  3. Third person auditory hallucination, running commentary
  4. Persistent bizarre delusions

OR two or more of:

  1. Persistent hallucinations
  2. Thought disorder
  3. Catatonic behaviour
  4. Negative symptoms
  5. Significant  behaviour  change At least one of:
  6. Bizarre delusions
  7. Third person auditory hallucinations
  8. Running commentary

OR two or more of:

  1. Delusions
  2. Hallucinations
  3. Disorganized speech
  4. Grossly disorganized behaviour
  5. Negative symptoms Duration More than 1 month 1 month of characteristic symptoms With 6 months of social/occupational dysfunction Subtypes Paranoid Catatonic Hebephrenic Residual Undifferentiated Simple Postschizophrenic depression Paranoid Catatonic Disorganized Residual Undifferentiated Chapters • F20 Schizophrenia • F21 Schizotypal disorder • F22 Persistent delusional disorder • F23 Acute and transient psychotic disorders • F24 Induced delusional disorders • F25 Schizoaffective disorder • F28 Other non-organic psychotic disorders • F29  Unspecified  non-organic psychosis

• 295.x Schizophrenia • 295.4 Schizophreniform disorder • 295.7 Schizoaffective disorder • 297.1 Delusional disorder • 297.3 Shared psychotic disorder • 298.8 Brief psychotic disorder • 298.9 Psychotic disorder NOS

© SPMM Course Other ‘schizophrenias’ in ICD-10 In acute and transient psychotic disorders (ICD-10), onset within two weeks is described as acute while the onset within 48 hours is called abrupt. Complete recovery within 2 to 3 months is the rule. It can be of polymorphic form or schizophrenia-like in it is presentation. In acute polymorphic psychosis, several hallucination and delusions changing in both type and intensity from day to day or even same day is noted. Schizotypal disorder is diagnosed in patients with eccentric manners, social withdrawal, magical thinking, suspiciousness, and obsessive ruminations but without resistance. The ruminations may have dysmorphophobic contents too. At least a 2-year history with schizophrenia being never diagnosed in the past is necessary for diagnosing schizotypal disorder. Schizotypal disorder includes older descriptions such as borderline schizophrenia, pseudo neurotic schizophrenia, etc. Is classified along with schizophrenia and related disorders in ICD-10 but along with Cluster A personality disorders in DSM-4. Schizotypy is more common in the other first-degree relatives of schizophrenic subjects than in the general population and the relatives of schizotypal subjects have an increased risk of schizophrenia. Persistent delusional disorders are characterised by a persistent, often life-long, typically  ‘non-bizarre’ delusion or a set of related delusions arising insidiously in mid-life or later. Transient auditory hallucinations may occur, but clear and persistent auditory hallucinations (voices), schizophrenic symptoms such as delusions of control and marked blunting of affect, and definite evidence of brain disease are incompatible with this diagnosis. However, the presence of occasional or transitory auditory hallucinations, particularly in elderly patients, does not rule out this diagnosis. The delusions need not be strictly monothematic though this is mostly the case. Affect, thought and behaviour are globally normal, but  patients’  attitudes   Schizophrenia Delusional Disorder Bizarre delusions are common Non-bizarre delusions (cannot be bizarre by ICD-10 definition) Daily functioning is significantly impaired Daily functioning is not significantly impaired Apart from delusions may have one or more of the following: x Hallucinations x Disorganized speech x Disorganized behaviour x Negative symptoms

These symptoms are almost always absent (tactile or olfactory hallucinations if at all present, are entangled in the content of a delusional complex) DSM-5 AND SCHIZOPHRENIA Presence of bizarre delusions or hallucinations is no longer sufficient as a sole criterion A for diagnosing schizophrenia. 2  of  5  ‘criterion-A’  symptoms  required  for  a   diagnosis with at-least one being a core positive symptom (delusions, hallucinations or disorganized speech) Schizophrenia subtypes (paranoid, disorganized, catatonic, undifferentiated, and residual types) have been removed. A dimensional method of rating severity for the core symptoms of schizophrenia is included. This proposes 8 dimensions (delusions, hallucinations, depression, mania, abnormal cognition, abnormal psychomotor behavior, disorganized speech and negative symptoms)

© SPMM Course and actions in response to these delusions are appropriate and may lead to dangerousness in some cases. Symptoms should have been present for at least 1 month (DSM-IV). ICD-10 specifies at least 3 months for delusional disorder. According to DSM-IV delusional disorder – ‘Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired, and behaviour  is  not  obviously  odd  or  bizarre’.  This   criterion is not explicit in ICD-10.

DSM-IV subtypes of delusional disorders Type Description Erotomania (de Clerambault syndrome) An erotic conviction that a person with higher status is secretly in love with the patient Seen most often in women though forensic samples are mostly males; may be associated with stalking or assaultive behaviour Grandiosity Patients believe they fill some special role, have some special relationship, or possess some special abilities. They may be involved with social or religious organisations Jealousy (Othello syndrome) Characterised by a delusion of infidelity. Patients possess the fixed belief that their spouse or partner has been unfaithful. Often patients try to collect evidence and/or attempt to restrict their partner's activities. Contributes to both wife battering and homicide. Persecutory Most common form of the delusional disorder. Patients are often convinced that others are attempting to hurt or harm them. This leads to them trying to obtain legal recourse, and sometimes turning violent. Somatic Varying presentations including patients who have repeated medical consultations requesting several treatment to those that show delusional concerns about a bodily infestation, deformity (delusional dysmorphophobia) or odour.

Mixed and unspecified types Please refer to delusional misidentification syndromes in Descriptive Psychopathology notes

Induced delusional disorders are accepted as a distinct diagnostic category and coded as F24 in ICD-10. This is a rare delusional disorder characterised by sharing of delusions between usually 2 or occasionally more persons who often have tightly knit emotional bonds. Only one person has genuine delusions due to underlying psychiatric disorder, most often schizophrenia or delusional disorder. On separation, the dependent individual may give up his or her delusions and the patient with the genuine delusions should be treated appropriately. In induced delusional disorders, induced hallucinations can be present, and this DSM-5 AND DELUSIONAL DISORDERS There is no requirement for delusions to be non-bizarre anymore Delusional symptoms must not be better explained by conditions such as obsessivecompulsive or body dysmorphic disorder with absent insight/delusional beliefs. Shared delusional disorder is no longer a separate diagnosis.

14 - Various atypical psychotic disorders

Various atypical psychotic disorders

© SPMM Course does not negate diagnosis. It is also called symbiotic psychosis or folie a deux. It is more common in couples and often involves nonbizarre delusions. Schizoaffective disorder is placed with F20 (psychoses) not F30 (affective disorders). In schizoaffective illness, both schizophrenic and mood symptoms are seen simultaneously in approximately equal proportion. The presence of mood-incongruent delusions is suggestive but not in itself sufficient to diagnose schizoaffective disorder; at least one typical schizophrenic symptom must be present. (Note - Affect neutral delusions are also included as incongruent delusions). The aetiology is assumed to be intermediate to that of schizophrenia and affective disorder. There are 2 subtypes: schizoaffective manic or depressive subtypes. Schizodepressive episodes are associated with a family history of schizophrenia and are usually less florid. The response to treatment is variable and may develop chronic negative symptoms. The depressive symptoms are more likely to signal a chronic course compared to manic presentations. In manic variant symptoms are florid but recovery is within weeks. Schizomanic episodes are associated with a family history of affective disorders. These patients respond well to mood stabilisers and recover rapidly. Various atypical psychotic disorders These disorders are recognized but not categorised separately in ICD-10. Bouffée délirante: The classical description of bouffée délirante was given by Legrain. Psychosis  of  sudden  onset,  ‘like  a  bolt  from  the  blue’; Polymorphous delusions and hallucinations of any kind; Clouded consciousnesses associated with emotional instability; Absence of physical signs, i.e. the disorder is not caused by any organic mental disorder; Rapid return to the premorbid level of functioning; and Relapses may occur, but individual episodes are separated by symptom-free intervals. The episodes develop in a predisposed individual and are caused by psychosocial factors (which also determine the content and form of the disorder), have a greater tendency to recover and seem never to end in deterioration. Process schizophrenia: The concept of process schizophrenia was first described by Langfeldt (1939). Langfeldt differentiated between two groups of psychoses usually diagnosed as schizophrenia: a group with  poor  prognosis,  labelled  ‘genuine’  or  ‘process’  schizophrenia,  and  a  group  with  good  prognosis,   labelled    ‘schizophreniform’  psychosis. (But later studies  that  reclassified  Langfeldt’s  100  cases  concluded   that  most  of  the  ‘schizophreniform  psychoses’  turned  out  to  be  affective  disorders  with  psychotic  features). The  term  ‘cycloid  psychoses’ was coined by Leonhard (1957) to describe endogenous psychotic syndromes characterized by a sudden onset, an admixture of symptoms belonging to the affective DSM-5 AND SCHIZOAFFECTIVE DISORDER A major mood episode (not merely mood symptoms) must be present for a majority (not  merely  ‘substantial  duration’) of the disorder’s  total  duration  after  Criterion  A   has been met. Diagnosis takes a more longitudinal perspective compared to DSM-IV

© SPMM Course disorders and of symptoms belonging to schizophrenia and phasic course. Leonhard subdivided the cycloid psychoses into three forms: motility psychoses, confusional psychoses and anxiety–blissfulness psychoses. Cycloid psychoses predominate in severe postpartum psychiatric disorders and are more common among women. Perris described the diagnosis as follows; psychotic episodes of sudden onset, mostly unrelated to stress, with good immediate outcome but with a high risk of recurrence, characterized by mood swings (from depression to elation) and at least two of the following: various degrees of perplexity or confusion; delusions  (of  reference,  influence  or  persecution)  and/or  hallucinations  not  congruent  with  mood; motility disturbances (hypo or hyperkinesia); occasional episodes of elation and states of overwhelming anxiety (pananxiety).

15 - 5. Classification of mood disorders

5. Classification of mood disorders

16 - Depressive disorder

Depressive disorder

17 - Bipolar affective disorder (BPAD)

Bipolar affective disorder (BPAD)

© SPMM Course 5. Classification of mood disorders Depressive disorder DSM-IV Major Depressive Disorder ICD 10 Depressive disorder Duration: Most of the day, nearly every day for at least two weeks.

Duration of at least two weeks is usually required for diagnosis for depressive episodes of all three grades of severity. Five or more of following symptoms; at least one symptom is either depressed mood or loss of interest or pleasure: (1) Depressed mood (2) Loss of interest (3) Significant weight loss* or 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, recurrent suicidal ideation without a specific plan, or suicide attempt or a specific plan Criterion A: Depressed mood, loss of interest and enjoyment, and reduced energy leading to increased fatigability and diminished activity

Criterion B: other common symptoms are: (1) Reduced concentration and attention (2) Reduced self-esteem and self-confidence (3) Ideas of guilt and unworthiness (4) Bleak and pessimistic views of the future (5) Ideas or acts of self-harm or suicide (6) Disturbed sleep (7) Diminished appetite

*To qualify as a diagnostic criterion, this must be an unintentional weight loss of at least 5% weight in one month. Note that reduced self-confidence is not listed in DSM.

The 4-6-8 rule for severity grading in ICD-10: For mild depressive episode at least 2 criterion A ‘core symptoms’ with four symptoms in total is required. For moderate depression, at least 2 criterion A with six symptoms in total is required. To diagnose a severe episode, at least 2 criterion A symptoms with eight symptoms in total is required.

Both DSM and ICD-10 define recurrent major depressive disorder if there is more than one episode of depression. In ICD-10, this diagnosis can be given to a patient with depression if there has been at least one previous major depressive episode separated by the current episode by at least two months.

Bipolar affective disorder (BPAD) BPAD is characterized by periods of prolonged and profound depression alternate with periods of excessively DSM-5 AND DEPRESSION In DSM-IV a diagnosis of depression cannot be given in the presence of bereavement for 2 months after the loss. This exclusion is now removed. A  specifier  “with  anxious  distress”  is added to rate the severity of bipolar or depressive disorders. This takes DSM closer  to  ICD’s  description  of  mixed   anxiety depression.

© SPMM Course elevated and irritable mood, known as mania. ICD 10 needs at least two mood episodes before a bipolar diagnosis can be considered, with complete recovery in between the episodes. The depressive episode must be present at least for 2 weeks; mania for 7 days (fewer if hospitalized); hypomania for 4 days and mixed episodes for 2 weeks before they can be diagnosed using ICD 10. In DSM, bipolar disorder can be diagnosed even with a single manic episode. BPAD is divided into two main broad types; Type 1 is characterised by full-blown mania or mixed mania and depression. Type 2 is characterised by recurrent depression and hypomania without episodes of either mania or mixed states. Except in the elderly, the natural course of mood episodes suggests that mania lasts for 4 months while depression for 6 months. This becomes longer in the elderly who show shorter periods of inter episodic remissions and more frequent episodes, which are considerably longer than those seen in working age adults.

ICD-10 bipolar affective disorder Current episode, hypomanic Current episode, manic without psychotic symptoms Current episode, manic with psychotic symptoms Current episode, mild or moderate depression Current episode, severe depression without psychotic symptoms Current episode, severe depression with psychotic symptoms Current episode, mixed Currently in remission Other bipolar affective disorders: Bipolar affective disorder, unspecified

In line with the depressive episode, a manic mood episode is also operationally defined in ICD and DSM. According to ICD, mania/manic episode is a distinct period of abnormally and persistently elevated, expansive, or irritable mood, with 3 (or more) characteristic symptoms of mania. By definition, the disturbance must be sufficiently severe to impair occupational and social functioning. Psychotic features may be present.

© SPMM Course DSM IV Manic episode ICD 10 Manic episode Duration: at least 1 week or any duration if hospitalised

Duration: Sustained for at least a week (unless it is severe enough to require hospital admission). Criterion A: Abnormally and persistently elevated, expansive, or irritable mood.

Criterion B: During the same period three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree: (1) Inflated self-esteem or grandiosity (2) Decreased need for sleep (3) More talkative than usual or pressure to talk (4) Flight of ideas or subjective racing of thoughts (5) Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli) (6) Increase in goal-directed activity (either socially, at work or school or sexually) or psychomotor agitation (7) Excessive involvement in pleasurable activities that have a high potential for painful consequences A mood that is predominantly elevated, expansive or irritable and definitely abnormal for the individual concerned. At least three of the following must be present (four if the mood is merely irritable), leading to severe interference with personal functioning in daily living: (1) Increased activity or physical restlessness; (2) Increased talkativeness ('pressure of speech'); (3) Flight of ideas or the subjective experience of thoughts racing; (4) Loss of normal social inhibitions resulting in behaviour which is inappropriate to the circumstances; (5) Decreased need for sleep; (6) Inflated self-esteem or grandiosity; (7) Distractibility or constant changes in activity or plans; (8) Behaviour which is foolhardy or reckless and whose risks the subject does not recognize e.g. spending sprees, foolish enterprises, reckless driving; (9) Marked sexual energy or sexual indiscretions.

Psychotic symptoms: In bipolar disorder, mood symptoms are prominent. However in its more severe form, mania may be associated with psychotic symptoms (usually mood-congruent, but may also be incongruent). Delusions and hallucinations are often  ‘changeable’  in  their  quality. Grandiose and persecutory delusions are common in psychotic mania. Auditory hallucinations are usually the second person in nature and are often consistent  with  the  patient’s  mood (e.g. religious revelations). Hypomania/hypomanic episode- ICD description of hypomania is a difficult concept. By definition, hypomania shares symptoms with mania, but these are evident to a lesser degree, not severe enough to interfere with social or occupational functioning or require admission to hospital, or include psychotic features. It includes mildly elevated, expansive, or irritable mood, increased energy and activity, increased self-esteem, talkativeness, over-familiarity, reduced need for sleep and difficulty in focusing on one task alone. Mixed states are cases where manic and depressive symptoms occur simultaneously. The occurrence of both manic/hypomanic and depressive symptoms in a single episode, present every day for at least 1 week (DSM-IV) or 2 weeks (ICD-10) DSM IV course specifiers for bipolar disorder:

18 - Other affective disorders

Other affective disorders

© SPMM Course o Rapid cycling: When at least four episodes of bipolar disorder occur within a period of one year, the condition is described  as  ‘rapid  cycling’.  Some  patients  with BPAD have more than 4 episodes per year; they are called rapid cyclers. 70-80% of rapid cyclers are women. Some of the factors associated with the rapid cycling include the use of tricyclic anti-depressant, low thyroxine level, being a female patient, Bipolar type 2 pattern of illness and the presence of neurological disease. Ultra-rapid cycling refers to the situation when fluctuations are over days or even hours. o Postpartum onset refers to the onset of mania, hypomania or depression with 4 weeks of childbirth. o Seasonal pattern refers to recurrences over several years with most episodes typically start (and end) at the same time each year.

Secondary Mania: This can occur as a result of misuse of alcohol or illicit drugs and can also occur with some prescribed drugs such as Levodopa and corticosteroids. The drug induced state wanes with the clearance of the drug responsible. It can also occur in certain organic conditions such as thyroid disease, multiple sclerosis and lesions involving cortical and or subcortical areas of the brain. Bipolar 3 is a variant used to describe minimal depression complicated by antidepressant-induced hypomania – these patients fall into bipolar spectrum (in ICD: this is coded as unspecified type). Other affective disorders Persistent affective disorders: This includes dysthymia and cyclothymia respectively for unipolar and bipolar patterns of symptoms that fail to meet criteria for severity but which are of long duration and sufficient to cause impairment. Dysthymia (ICD-10)/dysthymic disorder (DSM-IV): Chronic, mildly depressed mood and diminished enjoyment, not severe enough to be considered a depressive illness. Clinical features include depressed mood (< 2yrs), Reduced/increased appetite, Insomnia/hypersomnia, reduced energy/fatigue, Low self-esteem, Poor concentration and thoughts of hopelessness. Double Depression describes episodes of major depression superimposed on Dysthymia; the prognosis and treatment response may be worse. Cyclothymia:  There  is  also  a  subclinical  presentation  ”cyclothymia”  in  which  an individual may experience oscillating high and low moods, without ever having a significant manic or depressive episode (numerous periods of mild depression and mild elation) and not sufficiently severe or DSM-5 AND BIPOLAR DISORDER Criterion A for manic and hypomanic episodes now includes an emphasis on changes in activity and energy as well as mood Separate description of mixed episode has  been  removed.  A  new  specifier  “with   mixed  features”  has  been  added:  to   qualify for this specifier, there is no need to simultaneously fulfill criteria for both mania and major depressive episode. Presence of some features of the opposite pole of mood disturbance is sufficient.

© SPMM Course prolonged to fulfill the criteria for bipolar affective disorder or recurrent depressive disorder. An individual usually perceives these mood swings as being unrelated to life events.

Seasonal Affective Disorder (SAD) is included in ICD-10 in the Annex. Many patients exhibit a seasonal pattern for their affective illness. The classical presentation is depression with reversed biological features in winter. These do not constitute SAD. To diagnose SAD, ICD-10 specifies that 3 or more affective episodes must occur, with onset within the same 90 day period of the year, for 3 or more consecutive years. Remissions should occur within a defined 90-day period of the year. Seasonal episodes substantially outnumber any non-seasonal episodes that may occur. The affective episode is most commonly depressive in nature. Atypical features like hypersomnia, increased appetite, carbohydrate craving and weight gain are common. Most commonly, the onset is in autumn/winter (when daylight is less), and resolution is in spring/summer (when daylight is more). Phototherapy is a treatment that is popular in SAD. Bright light (10,000 lux) is considered to be superior to dim light. Daily exposure is usually for 1 to 2 hours. The benefit may become apparent within a few days. Maintenance treatment is given for the next few months until the usual time of remission.

DSM-5 AND DYSTHYMIA Dysthymia of DSM-IV is now reclassified as persistent depressive disorder, a diagnosis that includes both chronic major depressive disorder and the previous dysthymic disorder.

19 - 6. Classification of Neurotic Disorders

6. Classification of Neurotic Disorders

20 - Generalised anxiety disorder (GAD)

Generalised anxiety disorder (GAD)

© SPMM Course 6. Classification of Neurotic Disorders

Though the term ‘neurotic’  is retained, neurosis is not a major organising principle for classification in ICD10. DSM abandoned the name completely in 1994. In ICD-10, ‘Neurotic, Stress related and Somatoform disorders’ have been categorized under seven headings; phobic anxiety disorders, anxiety disorders (including panic disorder and generalized anxiety), obsessive compulsive disorders, reaction to severe stress and adjustment disorders, dissociative disorders (conversion) disorders, somatoform disorders and other neurotic disorders. In ICD-10, obsessive-compulsive disorder has a separate place in the classification but in DSM-4 it is classified as one of the anxiety disorders. ICD-10 contains a category of mixed anxiety and depressive disorder, but DSM-4 does not. In DSM-4, 12 distinct anxiety disorders are listed. Anxiety disorders include various combinations of psychological and physical symptoms not attributable to real danger and occurs as a persisting state (generalised anxiety disorder) or occurring either in attacks (panic disorder) Generalised anxiety disorder (GAD) GAD is characterised by prominent tension, excessive worry with generalised free-floating persistent anxiety and feelings of apprehension about everyday events leading to significant stress and functional impairment. To diagnose generalised anxiety disorder, ICD-10 requires duration of at least 6 months and the symptoms should have been present on most days during 6 months. The ICD-10 list contains 22 physical symptoms of anxiety whilst there are only 6 in the DSM-4 list. To diagnose GAD in ICD-10, at least 4 (with at least 1 from  ‘autonomic  arousal) of the following should be present:

  1. Symptoms of autonomic arousal: palpitations/tachycardia; sweating; trembling/shaking; dry mouth.
  2. ‘Physical’  symptoms:  breathing  difficulties;  choking  sensation;  chest  pain/discomfort;   nausea/abdominal distress.
  3. Mental state symptoms: feeling dizzy, unsteady, faint or lightheaded; derealisation/depersonalisation; fear of losing control, going crazy, passing out, dying.
  4. General symptoms: hot flushes/cold chills; numbness or tingling sensations.
  5. Symptoms of tension: muscle tension/aches and pains; restlessness/ inability to relax; feeling keyed up, on edge, or mentally tense; a sensation of a lump in the throat or difficulty swallowing.

21 - Panic disorder

Panic disorder

© SPMM Course 6. Other: exaggerated responses to minor surprises/being startled; concentration difficulties/mind going blank due to worry or anxiety; persistent irritability; difficulty getting to sleep due to worrying (List adapted from Oxford Handbook of Psychiatry- edition 2; pg. 357) Panic disorder A panic attack is a discrete episode of intense anxiety. It starts abruptly, reaches a peak within few minutes (10 minutes) and then starts to subside within 20-30 minutes. The attacks usually tend to occur spontaneously with no obvious precipitants. DSMIV specifies 13 physical symptoms of which at least 4 must be present to define a panic attack. It also specifies different types of panic attacks: i.e., situationally bound/cued, situationally predisposed, and unexpected/uncued panic. Panic disorder is characterised by recurrent panic attacks, which are not secondary to substance misuse, medical conditions, or another psychiatric disorder. Frequency of occurrence may vary from many attacks a day to only a few in a year. It is usually accompanied by persistent worry about having another attack, phobic avoidance of places or situations and significant behavioural changes related to the attack. Symptoms must be present for at least one-month duration to diagnose panic disorder. In ICD-10, panic disorder is graded as severe if there are more than 4 attacks per week in a 4-week period. According to ICD-10, for a definite diagnosis of panic disorder, several severe panic attacks should have occurred within a period of about 1 month: (1) In circumstances where there is no objective danger; (2) Without being confined to known or predictable situations; and (3) With comparative freedom from anxiety symptoms between attacks (although anticipatory anxiety is common)

According to DSM-IV at least one of the panic attacks, must be followed by at least one of the following three features for 1 month or more: (1) Anticipation of further attacks (2) Worry about implications or (3) Avoidance behaviour. Panic disorder can present either alone or with agoraphobia. In DSM–IV agoraphobia is not a distinct diagnostic entity; it can be only diagnosed along with panic disorder. In ICD-10, agoraphobia is held as a DSM-5 AND PANIC DISORDER Panic disorder and agoraphobia are separated in DSM-5. The controversial issue of the primacy of panic over phobic symptoms is now closed with the introduction of two distinct diagnoses, panic disorder and agoraphobia, each with separate criteria. Comorbid diagnosis is still possible. Only 2 types of panic attacks are recognised: unexpected and expected panic attacks.

22 - Phobic anxiety disorders

Phobic anxiety disorders

© SPMM Course primary diagnosis, with panic disorder being a qualifier for subcategorisation, in addition to being a diagnostic entity on its own but to be used only when no phobic disorder is notable. Phobic anxiety disorders According to Marks, the cardinal features of phobia include  the  ‘fear’  which  (1) Is out of proportion to the situation (2) Cannot be explained or reasoned away (3) Is beyond voluntary control (4) Leads to avoidance. Phobic anxiety is subjectively and behaviourally indistinguishable from other anxieties. Anticipatory anxiety is an important feature. Note that the phobic object is almost always external and not ‘currently dangerous’ for the patient. Internal phobic objects are noted in conditions such as nosophobia and dysmorphophobia; these conditions are classified under hypochondriasis. The circumstances provoking anxiety include situations (for example crowded places), objects like cockroaches and natural phenomena like thunder. The common types of phobic syndromes are agoraphobia, social phobia and specific (simple) phobias. Agoraphobia Agoraphobia is the commonest phobic disorder seen by psychiatrists. Agoraphobia is considered to be the most incapacitating of all phobias, with a lifetime prevalence of about 6-10% (Weismann and Merikangas 1986). It is more common in women between the age group of 15-35 and most cases begin in the early or midtwenties, though there is a further period of high onset in the mid-thirties. In later life, agoraphobic symptoms may develop secondary to physical frailty, with the associated fear of exacerbating medical problems or having an accident. The first episode typically occurs when a person (often a woman) is waiting for public transport or shopping in a crowded supermarket. Lack of immediately available escape route or exit is the main cognitive basis for the anxiety seen in agoraphobia. The three common themes that provoke anxiety and avoidance are of distance from home, crowding and confinement. Anticipatory anxiety can start even hours before the patient enters the feared situation. Avoidance of crowds, public places, or travelling away from home or being alone is a common feature. . Patients remain symptoms free if avoidance is successful. Symptoms usually fluctuate. It is not uncommon for agoraphobics to become totally housebound and, therefore, is sometimes called as housebound housewife syndrome, although not all patients with this condition are necessarily housewives. Agoraphobia may be accompanied by panic attacks, whether in response to environmental stimuli or arising spontaneously.

© SPMM Course As highlighted earlier, ICD-10 considers agoraphobia as the primary disorder with panic attacks being secondary and indicate severity of agoraphobia. The opposite is true in DSM-IV (but this issue has been resolved in DSM-V: see the box above). In cases where depression starts earlier, a diagnosis of depressive disorder should suffice, especially in late onset agoraphobia. Social Phobias Social phobia occurs more in small group settings where close scrutiny is possible. Two types of social phobia are noted in ICD-10 - (1) discrete type – anxiety manifested seen in specific occasions e.g. shy bladder (when using a public toilet) or fear of public speaking or (2) diffuse type – seen with exposure to any generic social task. Fear of vomiting in public is seen in some with social phobia. Blushing is also more common in social phobia than other anxiety disorders. The condition usually begins between the ages of 17 and 30. The first episode occurs in a public place, usually without any apparent reason. DSM describes social phobia as a marked and persistent fear of one or more social or performance situations where one gets exposed to unfamiliar people or to possible scrutiny by others. DSM also specifies the fear of humiliating or embarrassing oneself as an important feature, which helps to differentiate it from the anxiety seen in social situations when someone is paranoid. In addition, DSM stipulates that the sufferer must also recognize that the fear is excessive or unreasonable. DSM-IV specifies that in children, difficult social situations should involve interactions with peer, but an appreciation of the unreasonable or excessive nature of the fear is not required. A duration criteria of 6 months is also specified only for children, not adults. Specific phobias The age of onset of most specific phobias is in childhood; phobia of animals at average age of 7, blood phobia at 9, dental phobia at 12 (Ost, 1987) and claustrophobia -20yrs. It is more common among women. DSM-IV distinguishes 5 subtypes of phobias: animals, aspects of the natural environment, blood/injection/injury, situational, and other provoking agents. Specific phobia does not usually fluctuate and remain constant. Disease phobia related to situations where disease can be acquired and so avoided is still a specific phobia (nosophobia) and not hypochondriasis. Blood injury injection phobia is different from other phobias in that the response to exposure is not tachycardia and sympathetically driven heart rate, etc. Instead, a fainting response occurs where the DSM-5 AND SPECIFIC PHOBIAS In adults, there is no requirement for a subjective recognition that the fear is excessive or unreasonable. For all ages, duration of 6 months or more is applied.

23 - Obsessive compulsive disorder

Obsessive-compulsive disorder

© SPMM Course patient may drop fainting with low BP and bradycardia. There is a high prevalence of the condition among first-degree relatives of affected people (Marks 1988) About 5% of adults have a fear of the dental procedures. It can become so severe that all dental treatment is avoided, and dangerous caries develops (Gale and Ayer 1969). DSM-IV specifies that in adults, but not children, an appreciation of the unreasonable or excessive nature of the fear to diagnose specific phobias. The duration criteria of 6 months is specified only for children, not adults; as many irrational fears in children may be transient and developmental (this is changed in DSM-V, see the box above). Obsessive-compulsive disorder OCD is characterised by obsessional thinking, compulsive behaviour and often associated with marked anxiety and depression. Diagnosis according to ICD10 obsessions (thoughts, images, or ideas) and compulsions share the following features, all of which must be present: (1) Acknowledged as originating in the mind of the patient (2) Repetitive and unpleasant; at least one recognised as excessive or unreasonable (3) At least one must be unsuccessfully resisted (although resistance may be minimal in some cases) (4) Carrying out the obsessive thought or compulsive act is not intrinsically pleasurable

Obsessions can occur in several forms such as thoughts, ruminations, doubts, impulses and phobias. Obsessional slowness can occur as a result of Obsessional doubts or compulsive rituals. According to ICD-10, either obsessions or compulsions (or both) present on most days for a period of at least two successive weeks. Common symptoms: Checking (63%), washing (50%), fear of contamination (45%), doubting (42%), bodily fears (36%), counting (36%), insistence on symmetry (31%), aggressive thoughts (28%) (Data from OxfordHandbook of Psychiatry) Compulsive hoarding may be a neurobiologically distinct form of obsessive-compulsive disorder. Hoarding is notoriously difficult to treat by either psychological or pharmacological means. Symmetry obsessions tend to be chronic and treatment resistant. DSM-5 AND OCD A new exclusive chapter has been created to describe obsessive-compulsive and related disorders (not clubbed with anxiety disorders anymore). 2 new diagnoses are included in this chapter.

  1. Hoarding Disorder with core symptom being the inability (or persistent difficulty) to discard or give up possessions, regardless of their actual value.
  2. Excoriation Disorder (dermatillomania) with core symptom of compulsively  picking  one’s  own  skin  for   no apparent reason.

24 - Reactions to severe stress

Reactions to severe stress

25 - Acute stress reaction

Acute stress reaction

26 - Adjustment disorder

Adjustment disorder

© SPMM Course DSM-IV describes OCD as an anxiety disorder along with GAD and PTSD. A change has been made in DSM-V (see the accompanying box)

Reactions to severe stress Acute stress reaction Acute stress reaction (ICD) usually starts in an hour; resolution begins within 8 hours (if the stress is hit and run) or 48 hours if it is prolonged. The presence of physical exhaustion, organic factors or disease states increases the risk. The stressor is usually one that poses a serious threat to security, integrity and social position. The patient may initially be dazed with narrowed attention; disorientation is not uncommon as a result. Sometimes agitation and overactivity are seen. Partial or complete amnesia for the acute stress reaction is not unheard of. Dissociative symptoms seem to predominate in some. Having a history of previous psychiatric disorder does NOT negate a diagnosis of acute stress reaction. Acute stress disorder is a DSM concept similar to acute stress reaction. It is defined as starting while experiencing or after experiencing the distressing event, and lasting at least two days to at most four weeks. The emphasis is on dissociation, with onset specified to be within four weeks with symptoms lasting up to 4 weeks. In DSM-4, the diagnosis of acute stress disorder requires marked symptoms of anxiety and 3 from a list of 5 dissociative symptoms- depersonalization, derealisation, a sense of numbing or detachment, reduced awareness of the surrounding and dissociative amnesia. It also specifies that the response should involve intense fear, helplessness or horror. Debriefing is used widely for treatment but with little evidence that it is effective; in some cases it may even be counterproductive. Adjustment disorder Adjustment disorder is a diagnosis in both ICD-10 and DSM-IV. In DSM-IV, it is seen as a residual category for individuals with clinically significant distress without meeting criteria for a more discrete disorder such as depression or PTSD. It is a condition that refers to the psychological reactions arising in relation to adapting to new circumstances and occurs in someone who has been exposed to a psychosocial stressor like DSM-5 AND ADJUSTMENT DISORDER Reconceptualized as a heterogeneous array of stress-response syndromes that occur after exposure to a distressing (traumatic or nontraumatic) event. No longer a residual category for other anxiety disorders DSM-5 AND ACUTE STRESS DISORDER The stressor criterion requires being explicit as to whether qualifying traumatic events were experienced directly, witnessed, or experienced indirectly. The need for subjective response with intense fear, helplessness, or horror is removed now.

© SPMM Course divorce, separation etc., which is not catastrophic in nature. The usual presentations include anxiety, depression, poor concentration, irritability, anger, etc. with physical symptoms caused by autonomic arousals such as tremor and palpitations. Individual vulnerability plays a greater role in adjustment disorder than any other neurotic disorder. In adjustment disorder, patients may feel vulnerable to become violent though they rarely are violent. Conduct problems may be a presentation of adjustment disorder in adolescence; regressive phenomenon may be seen in children. The onset is more gradual than that of acute stress reaction, and the course is more prolonged. Social functioning is usually impaired. Onset must be within one month in ICD-10 and three months according to DSM-IV. Duration of adjustment disorder cannot exceed six months except in the subtype of prolonged depressive reaction, which can last up to 2 years. Brief depressive reaction subtype can last only up to a month. Also, the DSM-IV  Criterion  A2  regarding  the  subjective  reaction  to  the  traumatic  event  (e.g.,  “the  person’s   response involved intense fear, helplessness, or horror”)  has  been  eliminated. Bereavement and grief reaction Patients who experienced bereavement within last three months cannot be diagnosed to have an adjustment disorder. Normal bereavement is not coded in ICD 10 Chapter V, but in Chapter XXI. Normal grief: The classical symptoms experienced after bereavement which would include disbelief, shock, numbness, and feelings of unreality; anger; feelings of guilt; sadness and tearfulness; pining or searching, preoccupation with the deceased; disturbed sleep and appetite and, occasionally, weight loss; seeing or hearing the voice of the deceased (hallucinations of widowhood) Usually these symptoms gradually reduce in intensity, with the acceptance of the loss and readjustment (see the table below for the normal phases). A typical grief reaction lasts up to 12 months with an average duration of 6 months.

© SPMM Course Irrespective of age, a third of those who lose a spouse meet criteria for major depression in the first month after the death, and half of these remain clinically depressed one year later. However, in normal grief reactions substantial improvement is expected within two months to 6 months, and those who continue to meet criteria for major depression after this period should receive antidepressant or psychotherapy. Abnormal grief: It is also called as morbid or pathological or complicated grief. It is a grief reaction that is very intense, prolonged, delayed (or absent), or where symptoms outside the normal range are seen: e.g. preoccupation with feelings of worthlessness, thoughts of self-harm or suicide, excessive guilt, marked slowing of thoughts and movements, a prolonged period of lack of ability to function, hallucinatory experiences (other than the image or voice of the deceased) In ICD-10, abnormal grief reactions are coded as adjustment disorders. Abnormal grief includes Inhibited grief: Absence of expected grief symptoms at any stage Delayed grief: Avoidance of painful symptoms within two weeks of loss Chronic grief: Continued significant grief-related symptoms six months after loss ( Working with grieving adults | BJPsych Advances, http://apt.rcpsych.org/content/10/3/164_br (accessed March 31, 2015). Likely causes of abnormal grief include sudden and unexpected death of the deceased; insecure survivor; dependent or ambivalent relationship with the deceased; presence of dependent children and so cannot show grief easily; presence of previous psychiatric disorder in the survivor. Phase I Shock and protest includes numbness, disbelief and acute dysphoria Phase II Preoccupation includes yearning, searching and anger Phase III Disorganisation includes despair and acceptance of loss Phase IV Resolution gradual return to normality

27 - Posttraumatic stress disorder

Posttraumatic stress disorder

28 - Dissociative (conversion) disorders

Dissociative (conversion) disorders

© SPMM Course Posttraumatic stress disorder

The term PTSD denotes an intense prolonged and sometimes delayed reaction to an intensely stressful event. The essential features are hyperarousal, re-experiencing of aspects of the stressful event and avoidance of reminders. The principal symptoms of PTSD include Hyperarousal o Persistent anxiety o Irritability o Insomnia o Poor concentration Hypervigilance due to re-experiencing and enhanced startle response o Intrusions o Recurrent distressing dreams o Intensive intrusive imagery (flashbacks, vivid memories) o Difficulty in recalling stressful events at will Avoidance o Avoidance of reminders of the events- Efforts to avoid thoughts, feelings, or conversations associated with the trauma. Efforts to avoid activities, places, or people that arouse recollections of the trauma o Detachment-Feeling of detachment or estrangement from others o Emotional numbness o Diminished interest in activities (anhedonia) Both ICD-10 and DSM-IV require 2 or more persistent symptoms of increased psychological sensitivity and arousal (not present before exposure to the stressor) to diagnose PTSD. PTSD should start within six months of the trauma. In a small number of patients the onset is delayed i.e. after six months – termed  as  ‘probable PTSD’; in others the course may be chronic

6 months. Enduring personality changes are also reported following such trauma. In DSM-IV, a 3-months threshold is used to define chronic PTSD. Type 1 trauma refers to a single sudden catastrophic event e.g. accidents or rape. Type 2 trauma refers to a chronic repetitive insult against which the individual has no defence e.g. sexual abuse.

Dissociative (conversion) disorders Under this chapter in ICD-10 dissociative amnesia, fugue, trance/possession and disorders of movement/sensation (motor disorders, convulsions, anaesthesia/sensory loss) are included. DSM-5 AND PTSD The stressor criterion requires being explicit as to whether qualifying traumatic events were experienced directly, witnessed, or experienced indirectly. The need for subjective response with intense fear, helplessness, or horror is removed now. Along with the symptom clusters of reexperiencing and hyperarousal, the avoidance/numbing cluster is split into two. So now there are 4 clusters. Irritable, reckless or self-destructive behaviour is added to the description of arousal symptoms. Diagnostic threshold is lowered for children. In addition, a separate PTSD criterion has been added for children less than age 6.

© SPMM Course Dissociation is referred to as loss of integration among memories, identity, sensations and movements. It occurs closely in time with trauma. Theoretical concepts such as unconscious motivation or secondary gain are not used to describe this condition in ICD 10. Dissociation starts suddenly and terminated abruptly within weeks to months, Treatment is difficult in patients in whom it remains chronic (i.e. nearly a year). The concept of dissociative amnesia is centered on the loss of memory for important recent events, which is partial, patchy and selective. The characters of dissociative amnesia are o Episodic memory loss: retrograde only – no anterograde deficits. o Amnesia is for events that happened in a discrete period of minutes to years o The problem is not vague or inefficient retrieval but the strikingly complete unavailability of memories which were generally formed and were previously accessible. These events are traumatic or stressful. Amnesia can occur as a part of a dissociative fugue as well. In fugue purposeful journey away from home or   one’s   usual   base occurs. Self-care is usually maintained despite   ‘getting   lost’. Sometimes new identity can be assumed, and amnesia is present for past identity during the fugue; on recovery amnesia may be present for the fugue episode itself. As there is no cognitive impairment, the behaviour is usually normal. Perplexity and la belle indifference are frequent. Trance is a dissociative state where narrowed consciousness and limited but repeated movements are seen. Diagnosis of trance is made only if it is involuntary and not a culturally appropriate, intended practice. In addition, the trance states must be intrusive on activities of life and occur outside culturally sanctioned situations. Note that Temporal Lobe Epilepsy and head injury can also cause ‘organic’  trance.

Conversion / hysterical disorder is called a dissociative disorder of motor movement and sensations. The degree of disability in this disorder is very variable. La belle indifference is not universal, but common in conversion disorder. Close friends or relatives might have had the actual organic illness whose symptoms are present in a subject with conversion disorder. A milder and transient variety is seen in adolescent girls. Both Ganser syndrome and twilight states are included in dissociative states according to ICD-10. In DSM-IV, under dissociative disorders, only amnesia, fugue, dissociative identity disorder (multiple personalities), and depersonalization disorder are included. Conversion disorders and DSM-5 AND DISSOCIATIVE DISORDERS Depersonalisation disorder is now renamed as depersonalization/derealization disorder. Fugue is now a specifier for amnesia; not a separate diagnosis Dissociative identity disorder now includes pathological possession syndromes seen in some cultures. Both observed and reported changes in personality are considered in the

29 - Somatoform disorders

Somatoform disorders

© SPMM Course pain disorder are classified along with the somatoform disorder. In other words, all motor/sensory presentations are classed as conversion while memory/personality presentations are retained in dissociation category. Somnambulism is listed as a nonspecific dissociation in DSM-IV.

Seizures vs. pseudoseizures: At times it may be difficult to distinguish epilepsy from pseudoseizures (conversion). The following features are taken to be more suggestive of pseudoseizures:

Seizures vs. pseudoseizures Avoidance behaviour during seizures (to prevent serious injuries) Change in symptomatology of  seizure  patterns  e.g.  progression  or  ‘march’  that  is  inconsistent  with  cortical organization, asynchronous limb movements. Closing eyes during seizures, especially resisting opening of eyelids when attempted Dystonic posturing (this can happen in frontal seizures though rare) Emotional or situational trigger for the seizures and seizures provoked by suggestion Gradual onset and cessation of seizures (true seizures have a rapid crescendo and decrescendo) Tongue biting is rare and if present, usually the tip (not the side) of the tongue is bitten. Pelvic movements (especially forward thrusting) and side-to-side head movements Prolonged seizures (duration of 2 to 3 minutes); High seizure frequency but no history of injury from seizures. Lack of concern or an excessive or exaggerated emotional response Multiple unexplained physical symptoms Non response to antiepileptic drugs or a paradoxical increase in seizures with drug treatment Seizures that occur only in the presence of others or only when the patient is alone

Adapted from Elger RM. Psychogenic nonepileptic seizures: review and update. Epilepsy Behav 2003;4:207. Somatoform disorders Under this chapter in ICD-10, somatization disorder, hypochondriacal disorder, somatoform pain syndromes, autonomic dysfunction and undifferentiated somatoform disorder are included. All somatoform disorders are characterized by the lack of a psychological appraisal on the patient’s  part  along   with a resistance to consider presenting problems  as  one  of  ‘mental’  origin. Dissociative trance Possession trance x Altered narrow consciousness x Lost personal identity x No replacement with another identity x Stereotypic movements / utterances x Amnesia seen

x Altered narrow consciousness x Lost personal identity x Replaced with another identity x Stereotypic movements / utterances x Amnesia seen

© SPMM Course Somatization disorder is characterized by (a) at least 2 years of multiple and variable physical symptoms for which no adequate physical explanation has been found; (b) persistent refusal to accept the advice and reassurance of several doctors regarding the absence of a physical illness; (c) notable impairment of social and family functioning due to the symptoms and the illness behaviour. The term Briquet Syndrome or St. Louis Hysteria is sometimes applied to denote somatisation disorder. Family history of alcohol use and antisocial personality are common in women with somatisation disorder. Hypochondriacal disorder is characterized by 2 conditions (1) persistent belief of harboring atleast one serious physical illness even though repeated investigations and examinations have identified none or a persistent preoccupation with a presumed deformity or disfigurement (body dysmorphic type); (2) persistent refusal to accept the advice and reassurance of several doctors regarding the absence of a physical illness. Both nosophobia and nondelusional dysmorphophobia are classified as hypochondriasis in ICD-10. A 6 months duration criteria is specified in ICD-Diagnostic Criteria for Research (not in the regular diagnostic guidelines). Note that in DSM-IV, body dysmorphic disorder (dysmorphophobia) is considered as a separate diagnostic entity, within the chapter on somatoform disorders. It is described as a ‘subjective  description  of  ugliness  and  physical  defect  which  the   patient  feels  is  noticeable  to  others’.  It  is  an  excessive  concern   (overvalued idea) about trivial or non-existent physical abnormalities, which are perceived to be deformities. Beliefs about deformity that are of delusional intensity are classified under delusional disorders. With delusional intensity, the patient is constantly pre-occupied, convinced and tormented by abnormal belief that some part of his/her body is too large, too small or misshapen, which to other people, the appearance is normal or there is a trivial abnormality. The common complaints are about the nose, ears, eyes, mouth, buttocks, penis, breasts, but any part of the body may be involved. The affected person might think that other people notice and talk about his deformity and, therefore, would get involved in time consuming behaviours such as re-examining, repeated checking, involve in elaborated grooming rituals to hide the perceived defect and avoidance behaviour. This condition usually DSM-5 AND SOMATICSYMPTOMS In DSM-5, somatoform disorders are referred to as Somatic Symptom Disorders (SSD). Diagnosis of Somatization, Hypochondriasis, Pain Disorder and Undifferentiated Somatoform disorders are now eliminated. SSD can be diagnosed even if there is a medical disorder that explains the presenting symptoms. The emphasis is shifted from the actual physical symptoms to the maladaptive thoughts and feelings that surround these symptoms  (‘positive  features’). Individuals with high health anxiety but no somatic symptoms will be diagnosed to  have  ‘illness  anxiety  disorder’ Factitious disorder is placed under somatic symptom and related disorders. Body Dysmorphic Disorder has been moved from somatoform chapter to OCD & related disorders. A  “with  muscle   dysmorphia”  specifier  has  been  added  the description of body dysmorphic disorder.

30 - Other neurotic disorders

Other neurotic disorders

© SPMM Course begins in adolescence and is chronic with some fluctuations over time. It can occur as part of other psychiatric disorders such as depression or schizophrenia, or may be associated with social phobia or personality disorders Men and women are equally affected by hypochondriasis. In hypochondriasis patient looks for diagnosis, not symptom relief; he/she names the suspected disorder and may be more or less convinced about having the disorder. Somatoform autonomic syndrome refers to recurrent symptoms of autonomic arousal, such as palpitations, sweating, tremor, flushing, which often occur alongside other subjective symptoms referred to a specific organ or system despite having no evidence of structural or functional deficit in these systems. Patients refuse to be reassured regarding the absence of a physical illness despite the reassurances of different doctors. In somatoform pain syndrome, the major complaint is of persistent, severe, and distressing pain that is not explained by a physiological process or a physical disorder. Globus hystericus, psychogenic pruritus, psychogenic torticollis, teeth grinding (bruxism) and psychogenic dysmenorrhea are also included as  ‘other  somatoform  disorders’. Other neurotic disorders Neurasthenia, depersonalization-derealisation syndrome and other specified neurotic disorders (most of the culture-bound syndromes such as latah, dhat, koro) are included here. Psychogenic syncope and writer’s  cramp  are also described in this category. Neurasthenia is classified in F48 of ICD-10 as a neurotic disorder with either persistent and distressing complaints of increased fatigue after mental effort or persistent and distressing complaints of bodily weakness and exhaustion after minimal effort. This must be accompanied by at least two of the following features: 
- feelings of muscular aches and pains, dizziness
, tension headaches, 
 sleep disturbance, inability to relax, irritability
, dyspepsia. The diagnosis can only be made if other disorders classified in F40-47 section or depression cannot account for the presenting symptoms. Neurasthenia is the closest ICD-10 equivalent of Chronic Fatigue Syndrome. Depersonalization-derealization syndrome is diagnosed when either depersonalization or derealization symptoms are present in the presence of full insight (i.e. an acceptance of the subjective and spontaneous nature of the symptoms) and a clear sensorium. Depersonalization refers  to  the  perception  that  one’s feelings and/or experiences are detached, distant, not his or her own, lost (as if phenomenon). Derealization refers to the perception that objects, people, and/or surroundings seem unreal, distant, artificial, colourless or lifeless. Note that DSM classifies this condition as a dissociation disorder.

© SPMM Course Comparing and contrasting various disorders with somatic features Dissociation 1. Mental effects of a conflict 2. E.g. Amnesia, Loss of identity, alter personality

Conversion 1. Physical effects of a conflict 2. Paralysis, blindness, ataxia, anaesthesia, aphonia, seizures Somatoform/somatisation 1. Production of a symptom (positive) 2. Pain, vomiting, etc. 3. GIT and Musculoskeletal 4. Polysymptomatic Conversion 1. Loss of function (negative) 2. Paralysis, blindness, loss of balance, etc. 3. Neurological 4. Monosymptomati Hypochondriasis 1. Preoccupied with diagnosis 2. Concern: ‘One  dreadful  disease.' 3. Gastrointestinal features most common Somatisation 1. Preoccupied with symptoms 2. Concern: ‘One  excellent cure.' 3. Musculo-skeletal symptoms most common Malingering 1. Clearly intentional 2. Often monetary benefits 3. Military, compensation claims, etc. Factitious 1. ‘Truly puzzling’  with  ‘no  cause.' 2. Only gain is sick role 3. Seen in paramedical professionals 4. Munchaussen is severe form – wide doctor shopping is seen Factitious Disorders and Malingering DSM-IV considered factitious disorder and malingering in a separate chapter. In ICD-10, factitious disorders are considered along with personality disorders (F68). Malingering is not an ICD 10 mental disorder category but is coded in Z76.5. Munchausen by proxy is not coded in Chapter V of ICD10 but is discussed in T74.8.

31 - 7. Disturbances of behaviour and body physiol

7. Disturbances of behaviour and body physiology

32 - Eating Disorders

Eating Disorders

© SPMM Course 7. Disturbances of behaviour and body physiology

This  includes  various  disturbances  in  ‘behaviour’  and  abnormalities  across  a  mixture  of  ‘physiological   systems’  such  as  weight,  libido,  pregnancy, etc. It also includes non-dependence producing substance abuse such as analgesic abuse; antidepressant use; laxative use and steroid abuse. Eating Disorders The ICD-10 diagnostic criteria for Anorexia Nervosa describes the presence of low body weight as being 15% or more below the expected norm and BMI as 17.5 or less. Other features include x Self-induced weight loss, avoidance of fattening foods, vomiting, purging, excessive exercise, use of appetite suppressants. x Body image distortion, dread of fatness: overvalued idea, imposed low weight threshold. x Endocrine disturbances due to HPA axis dysfunction (Hypothalamic- pituitary-gonadal axis) manifesting as amenorrhoea, reduced sexual interest, raised GH levels, increased cortisol, altered Thyroid tests, abnormal insulin secretion. x Delayed/arrested puberty- if onset pre-pubertal. While diagnosing anorexia, Quetelet’s  body mass index is applicable only if age is more than 16.

In DSM-IV, amenorrhea is defined as at least three consecutive cycles being absent. DSM-IV also specifies two types: x Binge-eating/purging type: regularly engaged in bingeeating or purging behavior (such as self-induced vomiting or the use of laxatives, diuretics, or enemas). x Restricting type: no binge-eating or purging behavior In atypical anorexia nervosa, one or more of these essential features may be absent, or all are present but to a lesser degree. Atypical anorexia nervosa is described as “ a disorder that fulfills some of the features of anorexia nervosa but in which the overall clinical picture does not justify that diagnosis. For instance, one of the key symptoms, such as amenorrhoea or marked dread of being fat, may be absent in the presence of marked weight loss and weight-reducing behaviour. This diagnosis should not be made in the presence of known physical disorders associated with  weight  loss.” (ICD-10) x Several features are noted in patients with atypical anorexia when compared to those with typical anorexia. x Older age at onset and presentation x Recurring bouts of depression DSM-5 AND EATING DISORDERS Anorexia Nervosa: The requirement of amenorrhea as a condition for diagnosis has been removed. Bulimia Nervosa: The required minimum average frequency of binge eating/compensatory behaviour is changed from twice to once weekly.

© SPMM Course x Numerous somatic complaints x Unmet dependency needs, and x Little evidence of distortion in body image is seen. Differential Diagnoses for Anorexia Nervosa Physical Disorders Hyperthyroidism; other endocrine disorders; GI disorders resulting in vomiting, loss of appetite and/or malabsorption; Malignancy; Chronic infection. Hypothyroidism can also produce amenorrhea. Psychiatric disorders Depression, OCD with eating abnormalities, delusional behaviour concerning food, vomiting secondary to conversion (cyclical vomiting) Adapted from Focus. Fall 2004, Vol. II, No. 4 (p 528)

The ICD-10 diagnostic criteria for Bulimia Nervosa includes the following: x Persistent preoccupation with eating x Irresistible craving for food x Binges- episodes of overeating x Attempts to counter the fattening effects of food (self-induced vomiting, abuse of purgatives, periods of starvation, use of drugs e.g. appetite suppressants, thyroxine, diuretics) x Morbid dread of fatness, with imposed -low weight threshold In atypical cases of bulimia, one or more of these features may be absent. Neglecting insulin treatment is a weight reduction strategy seen in diabetics with bulimia. In DSM-IV, two types are specified: Purging and non-purging type. Obesity is not coded under eating disorders in ICD-10, but in chapter E66, which is not a mental disorder. Similarly  ‘loss  of  appetite’  is  not  considered  as  anorexia  even  if  it  is  ‘psychogenic’.

EDNOS- Eating disorder not otherwise specified is the most common eating disorder in the outpatient setting and is widely used by clinicians using DSM-IV.

Binge eating disorder (BED) is also increasingly recognised, but in ICD-10 this falls under atypical bulimia and in DSM-IV under EDNOS. Binge eating disorder is characterized by recurrent episodes of binge eating in the absence of extreme weight-control behaviour. This is often seen in a background of a general tendency to overeat. BED is associated with obesity; 5–10% of those seeking treatment for obesity have BED. Patients typically present in 40s. More males compared to other eating disorders, but only 25% of all binge-eating population is male. There is a high degree of spontaneous remission noted and stressed associated overeating is a common phenomenon. Self-help, behavioural weight loss programmes and CBT/IPT can help.

33 - Sleep disorders

Sleep disorders

© SPMM Course Sleep disorders ICD-10 chapter V (mental health) recognises only non-organic sleep disorders in which emotional causes are considered to be a primary factor. These are conditions that include dyssomnias (abnormalities in amount, quality, or timing of sleep) and parasomnias (abnormal episodic events occurring during sleep). Various chapters where sleep disorders are described in ICD-10 Hypersomnia, sleep-walking, sleep-terrors, nightmares, nonorganic sleep-wake disorder ICD-10 Chapter V, F51 Kleine-Levin syndrome, Narcolepsy, Disorders of the sleep - wake schedule, Sleep apnoea Chapter VI of ICD-10 Episodic movement disorders which include nocturnal myoclonus Chapter II Enuresis Chapter V, F98 (Childhood disorders) Primary nocturnal enuresis (considered to be due to delay in bladder development) Chapter XVIII

Sleep walking and sleep terrors are mostly childhood disorders and if adult onset or adult persistence is seen then significant psychological disturbance must be suspected; these are sometimes seen in early stages of dementia especially REM disorders in Lewy body dementia. In sleep terrors, several minutes of disorientation is noted on waking, and some perseverative behaviour may also be noted; recall if at all possible may be limited to fragmentary mental images. In contrast nightmares are well recalled; they may be associated with benzodiazepine, tricyclic or thioridazine use. Kleine-Levin syndrome is characterised by periodic episodes of hypersomnolence and hyperphagia. Associated features include a lack of concentration, mood changes, sometimes hypersexuality and anxiety. Laboratory tests may show some nonspecific changes in the electroencephalogram. However, clinical presentation and laboratory tests are normal during asymptomatic intervals. It most often presents in adolescent males, with complete recovery by the 3rd to 4th decade of life. Possible precipitating factors include excessive workload, febrile illness, and respiratory infections. Narcolepsy is characterised by excessive daytime drowsiness accompanied by a sudden onset of REM sleep (sleep seizure or narco lepsy) and sudden loss of muscle tone, provoked by strong emotions (cataplexy). Sleep paralysis and hynagogic hallucinations may also occur (between wakefulness and sleep) but are less common. Sleep paralysis is an episode of inability to move occuring between wakefulness and sleep. These attacks usually occur during adolescence and persist through life. Hypnagogic hallucinations are usually auditory in nature but may be visual or tactile, occur in about 25% of patients. Narcolepsy is virtually always familial, and 99.5 % of patients have the HLA Antigen DR-2 (DR15/DQ6). There is usually no structural brain lesion present in these patients.

34 - Sexual disorders

Sexual disorders

© SPMM Course A more commonly used classification system for sleep disorders is the International Classification of Sleep Disorders ICSD system. DSM closely resembles ICSD. Classification of sleep disorders as per this system is shown below: Dyssomnias x Primary insomnia x Primary hypersomnia x Circadian sleep disorders x Narcolepsy x Breathing related sleep disorders x Sleep state misperception Parasomnias (subdivided according to the phase of sleep with which they are associated) Arousal disorders (arising from NREM sleep) x Confusional arousals x Sleepwalking x Sleep terrors Sleep– wake transition disorders x Sleep starts x Sleep talking REM sleep parasomnias x REM behavioural disorder x Nightmares x Sleep paralysis Other parasomnias x Sleep bruxism x Sleep enuresis

Sexual disorders

Sexual dysfunctions are coded in F52 group. These disorders include the lack or loss of sexual desire (sexual aversion disorder, failure of genital response, orgasmic dysfunction, premature ejaculation, nonorganic vaginismus, nonorganic dyspareunia and excessive sexual drive).

According to DSM-IV, they can be classified into

Sexual desire disorders (sexual aversion, hypoactive sexual desire)

Sexual arousal disorder (female sexual arousal disorder, male erectile disorder)

Orgasmic disorders (female and male orgasmic disorder, premature ejaculation)

Sexual pain disorder (Dyspareunia, vaginismus)

Others (including those due to general medical or substance use disorders)

35 - Other physiological disorders

Other physiological disorders

© SPMM Course Other physiological disorders Puerperal disorders: F53 codes mild and severe puerperal mental disorders instead of classifying postnatal  disorders  as  ‘depression’  vs.  ‘psychosis’.  This  is  because,  it  is  well  recognised  that  separating   postnatal psychosis from depression is often difficult in practice. Non dependence abuse: F55 codes for the abuse of a wide variety of medicaments, proprietary drugs, and folk remedies and psychotropic drugs that do not produce dependence, such as antidepressants; laxatives; and analgesics

DSM-5 AND SEXUAL DISORDERS Genito-Pelvic Pain/Penetration Disorder is a new category that merges vaginismus and dyspareunia. The diagnosis of sexual aversion disorder has been removed.

36 - 8. Disorders of adult personality and behavio

8. Disorders of adult personality and behaviour

37 - Personality disorders

Personality disorders

© SPMM Course 8. Disorders of adult personality and behaviour Personality disorders x According to ICD-10, a diagnosis of personality disorders cannot be made in individuals younger than age 16 or 17. x Unlike other psychiatric disorders, personal distress is not a criterion for diagnosing personality disorders but this may be a feature seen during the course of a personality disorder. x At least three traits must be present from the list for diagnosing antisocial and borderline personality; the rest of the disorders requires at least four from the lists provided by ICD-10 diagnostic guidelines. x There are not many differences between ICD-10 and DSM-IV in the description of personality disorders. The notable exceptions are listed below. x Passive-Aggressive personality disorder and Depressive personality disorder are placed in an appendix of DSM-IV for research purposes. Passive aggressive is discussed with other personality disorders category in ICD10. DSM-IV ICD-10 Personality disorders are grouped into 3 clusters No clustering of personality disorders Schizotypal disorder is a personality disorder Not a personality disorder, but described as a variant of psychosis under the chapter on Schizophrenia Only single entity of borderline personality disorder Emotionally unstable personality disorder can be of impulsive or borderline type Features of Cluster A (odd, eccentric) personality disorders

© SPMM Course Features of Cluster B (dramatic, erratic) personality disorders

•Suspicious of other people and their motives. •Hold longstanding grudges against people, •Believe others are not trustworthy, •Emotionally detached •Feel other people are deceiving, threatening, or making plans against them. Paranoid personality disorder Paranoid personality disorder •Have difficulties in expressing emotions, particularly around warmth or tenderness. •Prefer loneliness •Aloof or remote, •Have difficulty in developing or maintaining social relationships •Remain unaware of social trends •Unresponsive to praise or criticism Schizoid personality disorder Schizoid personality disorder •Appear odd or eccentric; •May have illusions, magical thinking •Obsessions without resistance •May be members of quasi-cultural groups •Thought disorders and paranoia. •May believe in ESP, clairvoyance etc. •May have transient psychotic features Schizotypal personality disorder Schizotypal personality disorder

© SPMM Course •Lack of regard for the rights and feelings of other people. •Lack of remorse for actions that may hurt others. •Ignore social norms about acceptable behaviour, •May disregard rules and break the law. •Make relations easily but break them equally easily •A small proportion may be psychopathic Antisocial personality disorder Antisocial personality disorder •Poor self-image, •Unstable personal relationships, •Impulsive behaviour in areas such as personal safety and substance misuse. •May self-harm, feel suicidal and act on these feelings, •Experience instability of mood, •Have episodes of micro-psychosis. •Feelings of chronic emptiness •Fears of abandonment – rejection sensitivity hence form intense but short lasting relations Borderline personality disorder Borderline personality disorder •Extreme or over-dramatic behaviour. •May form relationships quickly, but be demanding •Attention-seeking. •May appear to others as being self-centred with shallow emotions •Being inappropriately sexually provocative. Histrionic personality disorder Histrionic personality disorder •Exaggerated sense of own importance. •Frequently self-centred •Intolerant of other people. •Grandiose plans and ideas •Cravings for attention and admiration. •Fear of dependency is the core conflictual theme. •Narcissistic injuries to pride lead to rage reactions. Narcissistic personality disorder Narcissistic personality disorder

© SPMM Course Features of cluster C (anxious, inhibited) personality disorders

DSM IV ICD 10 equivalent Cluster A (odd or eccentric disorders) Paranoid personality disorder Paranoid personality disorder Schizoid personality disorder Schizoid personality disorder Schizotypal personality disorder NONE - classified as a type of schizophrenia like disorder in ICD Cluster B (dramatic, emotional, or erratic disorders) Antisocial personality disorder Dissocial personality disorder Borderline personality disorder Emotionally unstable: 1. Impulsive 2. Borderline subtypes Histrionic personality disorder Histrionic personality disorder Narcissistic personality disorder NONE; mentioned in other personality disorders category Cluster C (anxious or fearful disorders) Avoidant personality disorder Anxious (avoidant) personality disorder Dependent personality disorder Dependent personality disorder Obsessive-compulsive personality disorder Anankastic personality disorder •Fears being judged negatively by other people •Feelings of discomfort in group or social settings. •May come across as being socially withdrawn •Have low self-esteem. •May crave affection but fears of rejection overwhelming. Avoidant personality disorder Avoidant personality disorder •Assumes a position of passivity, •Allowing others to assume responsibility for most areas of their daily life. •Lack self-confidence, •Feel unable to function independently of another person, •Feels own needs are of secondary importance. Dependent personality disorder Dependent personality disorder •Difficulties in expressing warm or tender emotions to others. •Frequently perfectionists •Often lack clarity in seeing other perspectives or ways of doing things, •Rigid attention to detail may prevent them from completing tasks. •Some may be hoarders, scrupulous with money •May not be able to delegate tasks; workaholics. Obsessive-Compulsive personality disorder Obsessive-Compulsive personality disorder

38 - Habit and impulse disorders

Habit and impulse disorders

39 - Gender identity disorders

Gender identity disorders

© SPMM Course Habit and impulse disorders Impulse control disorders (DSM-IV) or habit and impulse disorders (ICD 10 –chapter F 63) include the following: Kleptomania, Pyromania, Trichotillomania, Intermittent explosive disorder (not in ICD-10, but present in DSM-IV) & Pathological gambling. These disorders are typified by recurrent behaviours that appear irrational and result in harming the patient's own and others interests. This definition excludes the habitual excessive use of alcohol or drugs or sexual (F65.-) or eating (F52.-) related compulsive acts. A repeated failure  to  resist  impulses  (to  set  fire,  steal,  pull  one’s  own  hair  etc.)  is  a  common  theme. Gender identity disorders ICD-10 recognises three disorders: transsexualism, dual role transvestism and gender identity disorders of childhood. Gender identity is established  by  3  years;  it  is  an  individual’s  self  perception  of  being  male  or  female  and   depends on reared sex more than biological sex. It is resistant to change once established firmly. Gender dysphoria refers  to  feeling  of  incongruence  between  one’s  gender  identity  (I’m  a  man, or  I’m  a   woman)  and  one’s  phenotypic  appearance  (I  appear  like  a  man  or  woman). Various degrees of gender dysphoria exist. One mild form is recognized in ICD and DSM as dual role transvestism. Individuals with dual role transvestism wear clothes of the opposite sex in order to experience temporary membership in the opposite sex. The individual experiences a sense of appropriateness by wearing clothes of the other gender. There is no sexual motivation for the cross-dressing. The individual has no desire for a permanent change to the opposite sex. Dual role transvestism must be differentiated from fetishistic transvestism where cross-dressing results in sexual arousal often associated with masturbation or sexual activity. This is classified as a paraphilia (see below). A severe form of gender dysphoria is recognised as transsexualism in ICD and DSM. Transsexualism has the following criteria: x Persistent discomfort with his/her sex or sense of inappropriateness in the gender role of the sex x Strong and persistent cross-gender identification (not merely a desire for any perceived cultural advantages of being the other sex). This may be associated with the wish to  make  one’s  body  as  congruent   as possible with the preferred sex through surgery and hormone treatment. x The disturbance is not concurrent with a physical intersex condition and not due to other functional psychiatric disorders x The disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning x The transsexual identity has been present persistently for at least two years.

40 - Paraphilias (Disorders of sexual preference)

Paraphilias (Disorders of sexual preference)

© SPMM Course Most adult transsexuals, in fact, have origins of symptoms in childhood itself. Gender identity disorders of childhood can also be present in adolescents and children. A duration criteria of 6 months is appreciated for the pre-pubertal group. It is important to rule out chromosomal and endocrine problems in this group. In children, the large element of management is promoting the young person's tolerance of uncertainty and resisting pressures for quick solutions for the gender dysphoria. Surgical intervention is not justified until adulthood. Rarely some patients may have a form of body dysmorphic disorder where there is a persistent preoccupation with castration or penectomy without a desire to acquire the characteristics of the other sex. This may be classed as Gender identity disorder - NOS (not otherwise specified) or body dysmorphophobia. But this is not transsexualism. A transsexual person need not necessarily be homosexual – In other words, gender identity must be differentiated from sexual orientation. In gender dysphoria of childhood, 1/3rd to 2/3rd boys later appear homosexually oriented but very few persist as adult transsexuals. GIDs, at any age, are more common in males. Cross-dressing behaviour can also be transient in some associated with stressful times. Also, some individuals with mild gender dysphoria (to a degree that does not cause undue distress while in a mentally healthy state) may experience a marked intensification of a low-grade gender dysphoria when experiencing depressive episodes. Paraphilias (Disorders of sexual preference) Paraphilias, impulsive disorders and other habitual problems are coded under F60. In paraphilias, egosyntonic urges of sexual deviancy are seen (except in some cases of exhibitionism where the urges are reported as ego-alien). Klismaphilia is not a separate entity but is related to use of enemas to achieve sexual arousal. Necrophilia is  also  an  ‘other  paraphilia’  in  ICD-10. This refers to achieving sexual arousal by using dead bodies or other death related objects for sexual arousal. Paraphilias described in ICD-10 & DSM-IV Exhibitionism Expose genitals to achieve arousal Fetishism Use of inanimate objects to achieve arousal Paedophilia Sex with prepubescent child (<13) Sexual masochism Real, not simulated act of being humiliated, beaten or bound to achieve arousal Sexual sadism Real, not simulated act of inflicting psychological or physical suffering including humiliation of victim to achieve arousal DSM-5 AND PARAPHILIC DISORDERS All Paraphilic Disorders now include two new specifiers: In a Controlled Environment and In Remission.

© SPMM Course Fetishistic transvestism Crossdressing in heterosexual male to achieve arousal Voyeurism ‘Peeping-toms.' Frotteurism Touching and rubbing against non-consenting individual

Frotteurism  is  coded  as  ‘other  paraphilias’  in  ICD-10, but separate disorder in DSM-IV. Fetishistic transvestism is termed transvestic fetishism in DSM-IV.

41 - 9. Mental retardation

9. Mental retardation

© SPMM Course 9. Mental retardation ICD-10 specifies 4 degrees of mental retardation but advises that the IQ levels for grading severity of mental retardation be only for guidance and should not be applied rigidly in view of the problems of cross-cultural validity. Instead, the severity must be graded primarily by functioning ability. Degree of mental retardation defined using activities of daily life Profound: a minimal capacity for functioning, needs nursing care; constant aid and supervision required. IQ<20 Severe: Speech minimal; Can talk or learn to communicate. No profit from training in self-help. May contribute partially to self-maintenance under complete supervision later in life; IQ 20-34 Moderate: Profits from training in self-help; can be managed with moderate supervision. IQ 35-49 Mild: Can develop social and communication skills; minimal retardation and can be guided toward social conformity. IQ 50-69 The  term  ‘Mental  Retardation’  in DSM-IV is now replaced by  the  term  ‘Intellectual  Disability’ in DSM-V. Statement of Special Educational Needs (SEN): In England & Wales, following a statutory assessment by local  authority,  a  ‘statement  of  SEN’  will  be  prepared  to    set  out  what  special  help  the  child  needs,  and  to   consider the views and wishes of the child and their parents. The SEN statements consist of 6 essential parts as outlined below. The local educational board usually arranges for statutory assessments and initially issues a proposed statement, upon which the parents are invited to comment. The final statement has a legally binding effect on the board. It is possible to ask for reassessmeents to amend the statements.

© SPMM Course •Demographics details •List of reports gathered when preparing the statement Part 1 Part 1 •Description of nature and complexity of learning difficulties •The needs listed here will determine the care provided by the state. Part 2 Part 2 •List of arrangements and provisions proposed to be offered by the local authority/education board •Must also include monitoring arrangements •The outlined provisions MUST be met by the board Part 3 Part 3 •Details of school placement Part 4 Part 4 •Non-educational (health and social) needs •NOT legally binding on the local authority Part 5 Part 5 •Describes processes in place to meet noneducational needs Part 6 Part 6

42 - 10. Disorders of psychological development

10. Disorders of psychological development

© SPMM Course 10. Disorders of psychological development

In ICD-10 these include specific developmental disorders of speech and language (expressive, receptive language disorders, acquired aphasia with epilepsy), scholastic skills (reading, spelling, arithmetical skills), motor skills and pervasive developmental disorders. In non-pervasive disorders, the domain showing a deficit in development often improves with age. For example, in specific reading disorders of childhood, reading improves significantly though spelling difficulties persist longer. Pervasive developmental disorders include childhood autism, Asperger’s  syndrome,  Rett’s  syndrome,  atypical  autism  and   other childhood disintegrative disorder. Autism is defined by the presence of abnormal and/or impaired development evident before the age of 3 years, with abnormal functioning in all three areas of social interaction, communication, and restricted, repetitive behaviour. Unlike children with autism, children with Asperger’s  syndrome have normal language functions before the age of 3. Though language development is affected in autism, the children do not remain mute in most cases. Though not a diagnostic criteria, the presence of persistent gaze avoidance is strongly suggestive of pervasive  developmental  disorder  such  as  autism  /  Asperger’s.   Atypical autism is diagnosed if autistic features are seen but either of the age of onset is not satisfied or a failure to fulfill all three sets of diagnostic criteria is noted. Rett’s  syndrome is  seen  only  in  girls  in  whom  “apparently  normal  or  near-normal early development is followed by partial or complete loss of acquired hand skills and of speech, together with deceleration in head  growth,  usually  with  an  onset  between  7  and  24  months  of  age”  (ICD-10). Children also show handwringing stereotypies, hyperventilation and loss of purposive hand movements. During later ages, trunk ataxia and apraxia, associated with scoliosis along with choreoathetoid movements are seen. Epilepsy is also a common feature. Heller's syndrome or childhood disintegrative disorder is said to resemble dementia that occurs in childhood. Apparently normal development up to 2 years is followed by a loss of previously acquired skills and abnormal social functioning. DSM-5 AND AUTISM Autism Spectrum Disorder is a new description that will now include autism,  Asperger’s, Childhood Disintegrative Disorder, and Pervasive Developmental Disorder (not otherwise specified) in a single category. ASD is characterized by 1) deficits in social communication and social interaction and 2) restricted repetitive behaviors, interests, and activities (RRBs). If no RRBs are seen, then social communication disorder is diagnosed.

© SPMM Course Acquired Aphasia with Epilepsy is also called Landau-Kleffner syndrome. It is a disorder in which the child, despite the previous normal progress in language development, loses both receptive and expressive language skills (starting from age 3 – 7) but retains general intelligence. Epilepsy with paroxysmal abnormalities on the EEG is noted; these almost always originate from the temporal lobes bilaterally.

43 - 11. Disorders with childhood onset

11. Disorders with childhood onset

© SPMM Course 11. Disorders with childhood onset

Major ICD-10 categories in this chapter are highlighted in the table below: Divisions Subdivisions Hyperkinetic disorders (HKD) Rarely used (Attention and overactivity, hyperkinetic conduct disorder) Conduct disorders Conduct disorder & oppositional defiant disorder Emotional disorders specific to childhood Separation anxiety, phobias, social anxiety, sibling rivalry Social functioning disorders Elective Mutism, reactive attachment disorder Tic disorders Transient  tics,  Tourette’s  syndrome  (chronic  combined  motor   and vocal) Other behavioural and emotional disorders Enuresis, Encopresis, Pica, Stuttering

The hyperkinetic disorder is the ADHD equivalent in ICD-10. For ADHD/HKD, the diagnostic criteria are considered  to  be  more  ‘relaxed’  in  DSM  but  stricter  in  ICD-10. According to DSM-IV criteria, to meet the diagnosis of ADHD, some symptoms must be present before the age of 7 years, although ADHD is not diagnosed in many children until they are older than 7 years when their behaviours cause problems in school and other places. To confirm a diagnosis of ADHD, impairment from inattention and/or hyperactivity-impulsivity must be observable in at least 2 settings and interfere with developmentally appropriate functioning socially, academically, or in extracurricular activities and should persist for at least six months. ADHD is not diagnosed when symptoms occur in a child, adolescent, or adult with a pervasive developmental disorder, schizophrenia, or another psychotic disorder. Conduct disorder is an enduring set of antisocial and aggressive behaviours that evolves over time, usually characterized by aggression and violation of the rights of others. Diagnostic criteria: Children with conduct disorder are likely to demonstrate behaviours in the following four categories x Physical aggression or threats of harm to people, cruelty to people and animals x Destruction of their own property or that of others x Theft or acts of deceit x Frequent and serious violation of age-appropriate rules. (Like truanting or running away)

© SPMM Course Other features would include early sexual behaviour, lack of empathy, low self-esteem, and gang involvement. Usually, the features must be present for a substantial duration of minimum six months before entertaining the diagnosis. According to DSM-IV criteria, these behaviours should begin before the age of 13. [Childhood onset type – symptoms present before age 10, Adolescent onset type – symptoms develop after age 10] Oppositional Defiant Disorder: An enduring pattern of negative, hostile, disobedient and defiant behaviour, without serious violations of societal norms or the rights of others. Symptoms must be persistent and evident for at least 6 months. In oppositional defiant disorder, a child's temper outbursts, active refusal to comply with rules, tendency to blame others, spiteful and annoying behaviours exceed expectations for these behaviours for children of the same age. Oppositional Disorder is seen as a limited form of conduct disorder. According to ICD10, the oppositional disorder is a subtype of conduct disorder. DSM-IV excludes oppositional disorder if a conduct disorder is present. Separation anxiety disorder (SAD) is defined as developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attached. This anxiety will interfere with normal age appropriate functioning. The essential clinical feature of separation anxiety is excessive worry about losing or being permanently separated from a major attachment figure. Reactive attachment disorder: This disorder, occurring in infants and young children is characterised by persistent  abnormalities  in  the  child’s  pattern  of  social  relationships, which are associated with emotional disturbance and reactive to changes in environmental circumstances. Elective Mutism is a disorder characterized by a persistent failure to speak in specific settings (school) despite the full use of language at home or with family, may be found in younger children with social phobia. A child with selective mutism may remain completely silent or near silent, in some cases whispering instead of speaking out loud. Fear of strangers is a normal phenomenon in the second half of the first year of life. A degree of social apprehension is normal in early childhood in socially threatening/novel situations. Social anxiety disorder of childhood is a diagnosis that can be used before the age of 6 years, but only when the anxiety is unusual in degree and accompanied by problems in social functioning.

©"SPMM"Course" 57" Sibling!rivalry!disorder"is"characterized"by"“the"combination"of:"(a)"evidence"of"sibling"rivalry"and/or" jealousy;"(b)onset"during"the"months"following"the"birth"of"the"younger"(usually"immediately"younger)" sibling;"(c)emotional"disturbance"that"is"abnormal"in"degree"and/or"persistence"and"associated"with" psychosocial"problems”"(ICDL10)." " " " " " " " " " " " " " " " " " " DSM%5!AND!ADHD!! For'ADHD'the'onset'criterion'has'been' changed'from'“symptoms'that'caused' impairment'were'present'before'age'7' years”'to'“several'inattentive'or' hyperactive-impulsive'symptoms'were' present'prior'to'age'12”' Subtypes'have'been'replaced'with' presentation'specifiers'that'map'directly' to'the'prior'subtypes' A'comorbid'diagnosis'with'autism' spectrum'disorder'is'now'allowed' The'symptom'threshold'has'been' changed'for'adults'with'a'cutoff'for' ADHD'of'five'symptoms,'instead'of'six' required'for'younger'persons,'both'for' inattention'and'for'hyperactivity'and' impulsivity.' DSM%5!AND!CHIDHOOD!ONSET! DISORDERS!! A'new'diagnosis'“Disruptive'Mood' Dysregulation'Disorder”'has'been'added' to'reduce'the'misdiagnosis'of'Bipolar' Disorder'in'children.'Features'of' DMDD'include'a'persistent,'irritable' mood'and'frequent,'major'anger' outbursts'or'tantrums'three'or'more' times'a'week'for'more'than'a'year.' Separation'Anxiety'Disorder'and' Selective'Mutism'have'been'moved'from'' “Disorders'Usually'First'Diagnosed'in' Infancy,'Childhood,'or'Adolescence,”'to' “'Anxiety'Disorders”.'

© SPMM Course Notes produced using excerpts from: Cooper, J. E. (Ed.). (1994). Pocket Guide to the ICD-10 Classification of Mental and Behavioural Disorders: With Glossary and Diagnostic Criteria for Research: ICD-10/DCR-10. American Psychiatric Pub. American Psychiatric Association. (2013). DSM 5. American Psychiatric Association. First, M. B. (1994). Diagnostic and statistical manual of mental disorders. DSM IV-4th edition. APA. p, 97-327.

DISCLAIMER: This material is developed from various revision notes assembled while preparing for MRCPsych exams. The content is periodically updated with excerpts from various published sources including peer-reviewed journals, websites, patient information leaflets and books. These sources are cited and acknowledged wherever possible; due to the structure of this material, acknowledgements have not been possible for every passage/fact that is common knowledge in psychiatry. We do not check the accuracy of drug related information using external sources; no part of these notes should be used as prescribing information.