Psychopathology

Unit 1
What is psychopathology
• In short, this discipline can be understood as an in-depth study of
problems related to mental health. Just like pathology is the study of
the nature of disease (including causes, development, and
outcomes), psychopathology is the study of the same concepts within
the realm of mental health (or illness).
• This study of mental illness can include a long list of elements:
symptoms, behaviours, causes (genetics, biology, social,
psychological), course, development, categorization, treatments,
strategies, and more.
Signs of psychopathology
Signs of psychopathology vary depending on the nature of the
condition. Some of the signs that a person might be experiencing
some form of psychopathology include:
• Changes in eating habits
• Changes in mood
• Excessive worry, anxiety, or fear
• Feelings of distress
• Inability to concentrate
• Irritability or anger
• Low energy or feelings of fatigue
• Sleep disruptions
• Thoughts of self-harm or suicide
• Trouble coping with daily life
• Withdrawal from activities and friends
Diagnostic and Statistical Manual of Mental Disorders (DSM)
• The Diagnostic and Statistical Manual of Mental Disorders is the handbook widely used by
clinicians and psychiatrists in the United States to diagnose psychiatric illnesses.
• Published by the American Psychiatric Association (APA), the DSM covers all categories of
mental health disorders for both adults and children.
• DSM History the Diagnostic and Statistical Manual has been updated seven times since it was
first published in 1952.
DSM-I 1952
DSM-II 1968
DSM-III 1980
DSM-III-R 1987
DSM-IV 1994 297
DSM-IV-TR 2000 365
DSM -5 2022
International classification of diseases (
ICD)
• The ICD is a system similar to the DSM. Now in its eleventh version, the ICD
was developed over a century ago and was taken over by the World Health
Organization (WHO) when it was founded in 1948. So, how does the ICD-11
differ from the DSM-5-TR?
• First, the ICD-11 is produced by a global agency (the World Health
Organization), while the DSM-5-TR is produced by a national professional
association (the American Psychiatric Association). The ICD-11 is approved
by the World Health Assembly composed of health ministers from 193
WHO member countries.
• Second, the goal of the ICD-11 is to reduce the burden of disease globally.
It includes medical as well as mental y composed of health ministers from
193 WHO member countries.
• Second, the goal of the ICD-11 is to reduce the burden of disease globally.
It includes medical as well health mental diagnosis.
Dsm-5
New disorders
Social (pragmatic) Communication Disorder.
Disruptive Mood Dysregulation Disorder.
Premenstrual Dysphoric Disorder
Hoarding Disorder
Excoriation(skin-picking) Disorder.
Disinhibited Social Engagement Disorder
Binge Eating Disorder
Central Sleep Apnea (split from breathing-related sleep disorder).
..
• Sleep-Related Hypoventilation (split from breathing-related sleep disorder).
• Rapid eye movement sleep behaviour disorder(parasomnia NOS)
• Restless legs syndrome(dyssomnia NOS)
• Caffeine withdrawal
• Cannabis withdrawal.
• Major neurocognitive Disorder with Lewy Body Disease(Dementia Due to other
Medical Conditions).
• Mild Neurocognitive Disorder.(precursor to dementia).
Neurocognitive disorders
• In DSM-5, the cluster of neurocognitive disorders is characterised by
the presence of cognitive deficits that are the most prominent and
defining features of a given condition.
• The disorders in the neurocognitive cluster are also characterized by
‘acquired’ deficits, which represent a decline from a previously
attained level of functioning, and are not neurodevelopmental
deficits present from birth or early life.
• When referring to neurocognitive disorders, it is important to
delineate the domains of cognitive function that are likely to be
affected.
..
SUBDIVIDING THE CLUSTER.
The neurocognitive disorders cluster comprises three syndromes, each with a range of
possible aetiologies: delirium, mild neurocognitive disorder and major neurocognitive
disorder (Dementia).
1. Delirium
• This neurocognitive disorder is characterised by disturbance in attention that makes
it difficult for the individual to direct, sustain and shift their focus.
• The individual is, therefore, likely to have reduced orientation to their environment,
and at times to oneself. This symptom has sometimes been referred to as ‘reduced
level of consciousness’ or confusional state, although disturbance in awareness is a
more accurate description.
• The disturbance of awareness tends to develop over hours to days, and typically
fluctuates in the course of the day, often worsening in the evening.
• Delirium can be caused by an underlying medical condition, substance intoxication
or withdrawal, exposure to toxins, or a combination of these factors. Patients may
be hyperactive, hypoactive or have a mixed level of activity.
 ..
2. Mild and major neurocognitive disorder
• Clear decline from a previous level of functioning in one or more of the key
cognitive domains.
• Attention may be disturbed in these disorders, but, in contrast to delirium,
this disturbance is not the core feature, and awareness of the environment
is generally retained, except in very severely impaired patients.
• The diagnoses of mild or major neurocognitive disorder are not made if the
cognitive deficits occur in the context of persistent delirium, but can be
made in patients for whom delirium manifests and then resolves.
..
a). Mild cognitive disorders
• DSM-5 describes the level of cognitive decline in mild neurocognitive
disorder to be “modest,” leaving it up to the diagnostician to make the final
judgement on the severity.
• Mild neurocognitive disorder needs to be distinguished from both normal
cognitive ageing and major neurocognitive disorder (or dementia), even
greater reliance on neuropsychological assessment is called for in mild than
in major neurocognitive disorder.
• Serial assessments might be necessary to document decline, but the results
must be interpreted cautiously in view of practice effects, variable test–
retest reliability, and the dearth of normative data on cognitive decline.
 .. Neurocognitive disorder
b). Major
• Major Neurocognitive disorder mostly obviates the older concept of
dementia; even though DSM-5 retains ‘dementia’ in parentheses to
indicate that it may still be used.
• The term dementia is most commonly used to refer to older individuals—
very often synonymously with AD—and is less likely to be used to
describe younger people with severe cognitive deficits due to, for
example, traumatic brain injury or HIV infection.
• We expect that ‘dementia’ will continue to be used for elderly patients
and in many clinical settings owing to familiarity and historical continuity,
but we also expect that major neurocognitive disorder will be a more
suitable diagnosis for many younger patients.
..
• In many patients with neurocognitive disorders, there is evidence for a
causative disorder such as: Parkinson disease, Huntington disease,
traumatic brain injury, HIV infection or AIDS, or stroke.
• In other patients, the cognitive and behavioural symptoms manifest first,
and the longitudinal course reveals aetiologies such as in AD(Alzheimer
disease), cerebrovascular disease, frontotemporal lobar degeneration
and Lewy body disease.
• Occasionally, and especially in older individuals, there can be multiple
causative factors, all of which should be recognized, but with primacy or
salience assigned to one or two. For example, major neurocognitive
disorder may be due to pathology produced by AD and cerebrovascular
disease, which should both be diagnosed.
• DSM-5 does not permit the diagnosis of mild or major neurocognitive
disorders if the cognitive deficits can be better explained by another
mental disorder, such as major depression or schizophrenia.
... Many patients with neurocognitive disorders,
there is evidence for a causative disorder such as:
..
• In many patients with neurocognitive disorders, there is evidence for a
causative disorder such as: Parkinson disease, Huntington disease, traumatic
brain injury, HIV infection or AIDS, or stroke.
• In other patients, the cognitive and behavioural symptoms manifest first, and
the longitudinal course reveals aetiologies such as in AD(Alzheimer disease),
cerebrovascular disease, frontotemporal lobar degeneration and Lewy body
disease.
• The aetiological subtype criteria are the same for both mild and major
neurocognitive disorders, although establishing aetiology in mild
neurocognitive disorder is more difficult and may, therefore, have to remain
unspecified in many patients.
NEUROCOGNITIVE DISORDER (DEMENTIA) DUE TO AD
(ALZHEIMER’S DISEASE).
• Alzheimer's disease is a neurodegenerative disorder with an insidious onset
and gradual progression of cognitive deficits.
• In a typical case, decline in learning and memory is an early and
predominant feature, and the decline is progressive, without extended
plateaus.
• For the DSM-5 diagnosis of major neurocognitive disorder due to AD,
decline in at least two cognitive domains is necessary, one of which should
be learning and memory; for mild neurocognitive disorder due to AD, the
learning and memory deficit is sufficient for diagnosis.
..
• In the absence of evidence for mixed aetiology (such as cerebrovascular
disease or another neurological dis order), or in the presence of a
causative mutation in APP, PSEN1 or PSEN2 indicated by definite family
history or genetic testing, insidious onset and gradual progression
increase the certainty of the diagnosis to ‘probable’ in the case of major
neurocognitive disorder.
• For mild neurocognitive disorder, a more conservative standard is
warranted, and a ‘probable’ diagnosis is only reached if there is evidence
of a causative mutation for AD, and a ‘possible’ diagnosis requires only
the typical clinical features.
VASCULAR NEUROCOGNITIVE DISORDER.

• The concept of vascular neurocognitive disorder is broad and includes both

ischaemic and haemorrhagic lesions, as well as changes due to small vessel
disease.
• The diagnosis of vascular neurocognitive disorder can, therefore, be made in
the absence of patient history or physical signs suggestive of stroke.
• In this case, the clinical features should suggest damage due to small vessel
disease, including prominent disturbance in processing speed and frontal–
executive function, and physical signs consistent with stroke or small vessel
disease, such as hemiparesis, pseudo bulbar palsy and visual field defects,
and/or neuroimaging evidence such as multiple lacunar infarcts or extensive
and confluent white matter lesions.
• The development or worsening of cognitive deficits following a
cerebrovascular event increases the certainty of the diagnosis.
• ..
No bio- markers of vascular neurocognitive disorder, other than
neuroimaging, have been established.
• The diagnosis of probable vascular neurocognitive disorder is
therefore made if the clinical syndrome is supported by
neuroimaging, follows a documented cerebrovascular event, or if
both clinical and genetic evidence of cerebrovascular disease is
present,
for example in patients with cerebral autosomal dominant
arteriopathy with subcortical infarcts and leukoencephalopathy.
Conclusion
• DSM-5 is the first major attempt to classify the various neurocognitive disorders
with sets of criteria that are internally consistent and use common terminology.
• The DSM-5 uses a clinical approach to diagnosis, and recognizes that the
neurocognitive cluster is a heterogeneous group of disorders occurring throughout
the life span.
• Providing a parallel format across the various disorders simplifies the approach to
differential diagnosis.
• The DSM-5 also attempts to disentangle cause from consequence, and is written in
the recognition that multiple and nonexclusive factors may cause a given disorder.
• It makes explicit the fact that neurocognitive disorders lie on a continuum, and many
individuals have a milder form of the disorder that is not severe enough to be called
dementia.
• The DSM-5 does not imply that mild neurocognitive disorder will necessarily
progress to major neurocognitive disorders
..
DELIRIUM
• Delirium is a state of acute brain failure that lies between normal
wakefulness and stupor or coma. The word comes from the Latin
‘delirare’,meaning to be out of one’s furrow or track.
• Delirium can occur in a person of any age. However, the elderly are at
particularly high risk, perhaps because of brain changes caused by normal
aging that lead to reduced “brain reserve.”
 .. FOR DELIRIUM
CRITERIA
I. Disturbance in attention (i.e., reduced ability to direct, focus, sustain,
and shift attention) and awareness (reduced orientation to the
environment).
II. The disturbance develops over a short period of time (usually hours
to a few days), represents a change from baseline attention and
awareness, and tends to fluctuate in severity during the course of a day.
III. An additional disturbance in cognition (e.g., memory deficit,
disorientation, language, visuospatial ability, or perception).
iv. The disturbances in criteria I and III are not better explained by
another pre-existing, established, or evolving neurocognitive disorder
and do not occur in the context of a severely reduced level of arousal,
such as coma.
v. There is evidence from the history, physical examination, or laboratory
findings that the disturbance is a direct physiological consequence of
another medical condition, substance intoxication or withdrawal (i.e.,
due to a drug of abuse or to a medication), or exposure to a toxin, or is
due to multiple etiologies
..COMMON CAUSES OF DELIRIUM
• Surgery.
• Cardiac surgery.
• Cognitive decline, longer hospital stays, more health problems.
• Head injury and infection.
• Drug intoxication or withdrawal.
• Toxicity from medications.
..Medical induce Delirium
• Delirium is common on medical wards, where it may be mistaken for other mental
disorders, including psychosis, depression, mania, “hysteria,” or personality
disorder.
• Delirium has the overall highest incidence of all mental disorders. By some
estimates, up to half of hospitalized elderly patients become delirious. It is more
common in children and the elderly than in young and middle-aged adults.
• Delirium has many aliases. Neurologists and internists call it acute confusional
state.
• Other terms sometimes used for delirium include toxic psychosis, acute brain
syndrome, and metabolic encephalopathy. These terms are useful to know when
you are discussing a delirious patient with clinicians who do not specialize in
mental health.
• Some clinicians regard delirium as a state of agitated mental confusion during
which the patient experiences visual hallucinations that are unusually vivid.
 ..
Substance induce delirium
• People who abuse street drugs or alcohol are at serious risk for developing
a delirium.
• The name of the substance/medication intoxication delirium begins with
the specific substance (e.g., cocaine, dexamethasone) that is presumed to
be causing the delirium.
• The diagnostic code is selected from the table included in the criteria set,
which is based on the drug class and presence or absence of a comorbid
substance use disorder.
• For substances that do not fit into any of the classes (e.g.,
dexamethasone), the code for “other substance” should be used; and in
cases in which a substance is judged to be an etiological factor but the
specific class of substance is unknown, the category “unknown substance”
should be used.
..
Delirium due to multiple etiologies:
• There is evidence from the history, physical examination, or laboratory
findings that the delirium has more than one etiology (e.g., more than one
etiological medical condition; another medical condition plus substance
intoxication or medication side effect).
• Probably more patients than are ever recognized have multiple causes for
delirium. Many such diagnoses are undoubtedly missed because the
clinician is aware of one cause and fails to identify the others.
• The signs and symptoms do not differ from those in the foregoing
examples, but of course, successful treatment can hinge heavily upon
accurate identification of all contributing factors.
• Delirium due to multiple etiologies is not really a single diagnosis—it is a
collection of two or more diagnoses occurring in a single patient.
Unspecified Delirium
..
Use other specified or unspecified delirium as a catch-all category for
any delirium that does not meet the criteria for one of the previously
described types.
..
Specifiers
• Regarding course, in hospital settings, delirium usually lasts about 1 week,
but some symptoms often persist even after individuals are discharged from
the hospital.
• Individuals with delirium may rapidly switch between hyperactive and
hypoactive states.
• The hyperactive state may be more common or more frequently recognized
and often is associated with medication side effects and drug withdrawal.
The hypoactive state may be more frequent in older adults.
..
Associated Features Supporting Diagnosis
• Delirium is often associated with a disturbance in the sleep-wake cycle.
This disturbance can include daytime sleepiness, night-time agitation,
difficulty falling asleep, excessive sleepiness throughout the day, or
wakefulness throughout the night.
• In some cases, complete reversal of the night-day sleep-wake cycle can
occur. Sleep-wake cycle disturbances are very common in delirium and
have been proposed as a core criterion for the diagnosis.
• The individual with delirium may exhibit emotional disturbances, such as
anxiety, fear, depression, irritability, anger, euphoria, and apathy. There
may be rapid and unpredictable shifts from one emotional state to another.
• The disturbed emotional state may also be evident in calling out,
screaming, cursing, muttering, moaning, or making other sounds.
• These behaviours are especially prevalent at night and under conditions in
which stimulation and environmental cues are lacking.
 ..
Development and Course
• While the majority of individuals with delirium have a full recovery with or
without treatment, early recognition and intervention usually shortens the
duration of the delirium.
• Delirium may progress to stupor, coma, seizures, or death, particularly if the
underlying cause remains untreated.
• Mortality among hospitalized individuals with delirium is high, and as many
as 40% of individuals with delirium, particularly those with malignancies
and other significant underlying medical illness, die within a year after
diagnosis.
 ..
Risk and Prognostic Factors
• Environmental. Delirium may be increased in the context of functional
impairment, immobility, a history of falls, low levels of activity, and use of
drugs and medications with psychoactive properties (particularly alcohol
and anticholinergics).
• Genetic and physiological. Both major and mild NCDs can increase the risk
for delirium and complicate the course. Older individuals are especially
susceptible to delirium compared with younger adults.
• Susceptibility to delirium in infancy and through childhood may be greater
than in early and middle adulthood. In childhood, delirium may be related
to febrile illnesses and certain medications (e.g., anticholinergics).
Treatment / Management
• The main treatments for delirium are based on non-pharmacologic
interventions, as there are no FDA-approved medications for the treatment or
prevention of delirium. Preventing delirium from occurring is the most
efficacious intervention.
• In order to prevent delirium, avoidance and elimination of causes and risk
factors have to be prioritised.
• Many medications have been evaluated for the prevention and treatment of
delirium; however, multiple studies have shown no clear evidence that they
reduce the incidence of delirium compared with placebo, possibly due to the
multifactorial etiology of delirium.
• Delirium, especially if hyperactive and associated with agitation and
aggression, can result in dangerous situations for patients and health care
professionals. Antipsychotics are commonly used as first-line medication in
order to confront these situations, although the evidence for their use to
treat delirium in non-ICU or ICU settings is limited.
Dementia of the Alzheimer’s type
A. The criteria are met for major or mild neurocognitive disorder.
B. There is insidious onset and gradual progression of impairment in one or more cognitive
domains (for major neurocognitive disorder, at least two domains must be impaired).
C. Criteria are met for either probable or possible Alzheimer’s disease as follows:
For major neurocognitive disorder:
Probable Alzheimer’s disease is diagnosed if either of the following is present; otherwise,
possible Alzheimer’s disease should be diagnosed.
1. Evidence of a causative Alzheimer’s disease genetic mutation from family history or
genetic testing.
2. All three of the following are present:
a. Clear evidence of decline in memory and learning and at least one other cognitive domain
(based on detailed history or serial neuropsychological testing).
b. Steadily progressive, gradual decline in cognition, without extended plateaus.
c. No evidence of mixed etiology (i.e., absence of other neurodegenerative or
cerebrovascular disease, or another neurological, mental, or systemic disease or condition
likely contributing to cognitive decline).
..
For mild neurocognitive disorder:
• Probable Alzheimer’s disease is diagnosed if there is evidence of a
causative Alzheimer’s disease genetic mutation from either genetic testing
or family history.
• Possible Alzheimer’s disease is diagnosed if there is no evidence of a
causative Alzheimer’s disease genetic mutation from either genetic testing
or family history, and all three of the following are present:
1. Clear evidence of decline in memory and learning.
2. Steadily progressive, gradual decline in cognition, without extended
plateaus.
3. No evidence of mixed etiology (i.e., absence of other neurodegenerative
or cerebrovascular disease, or another neurological or systemic disease or
condition likely contributing to cognitive decline).
D. The disturbance is not better explained by cerebrovascular disease,
another neurodegenerative disease, the effects of a substance, or another
mental, neurological, or systemic disorder.
 ..
Diagnostic Features
• (Criterion A), the core features of major or mild NCD due to Alzheimer’s
disease include an insidious onset and gradual progressions of cognitive
and behavioral symptoms (Criterion B).
• The typical presentation is amnestic (i.e., with impairment in memory
and learning).
• A level of diagnostic certainty must be specified denoting Alzheimer’s
disease as the “probable” or “possible” etiology (Criterion C).
• If the etiology appears mixed, mild NCD due to multiple etiologies should
be diagnosed. In any case, for both mild and major NCD due to
Alzheimer’s disease, the clinical features must not suggest another
primary etiology for the NCD (Criterion D).
..Associated Features Supporting Diagnosis
• Approximately 80% of individuals with major NCD due to Alzheimer’s
disease have behavioral and psychological manifestations; these
features are also frequent at the mild NCD stage of impairment.
• These symptoms are as or more distressing than cognitive
manifestations and are frequently the reason that health care is
sought.
• At the mild NCD stage or the mildest level of major NCD, depression
and/or apathy are often seen.
• With moderately severe major NCD, psychotic features, irritability,
agitation, combativeness, and wandering are common.
• Late in the illness, gait disturbance, dysphagia, incontinence,
myoclonus, and seizures are observed.
 ..
Prevalence
• The prevalence of overall dementia (major NCD) rises steeply with age.
In high-income countries, it ranges from 5% to 10% in the seventh
decade to at least 25% thereafter.
• U.S. census data estimates suggest that approximately 7% of
individuals diagnosed with Alzheimer’s disease are between ages 65
and 74 years, 53% are between ages 75 and 84 years, and 40% are 85
years and older.
• The percentage of dementias attributable to Alzheimer’s disease
ranges from about 60% to over 90%, depending on the setting and
diagnostic criteria.
 ..
Development and Course
• Major or mild NCD due to Alzheimer’s disease progresses gradually,
sometimes with brief plateaus, through severe dementia to death.
• The mean duration of survival after diagnosis is approximately 10 years,
reflecting the advanced age of the majority of individuals rather than
the course of the disease; some individuals can live with the disease for
as long as 20 years.
• Late-stage individuals are eventually mute and bedbound. Death most
commonly results from aspiration in those who survive through the full
course.
 ..
Culture-Related Diagnostic Issues
Detection of an NCD may be more difficult in cultural and socioeconomic
settings where memory loss is considered normal in old age, where older
adults face fewer cognitive demands in everyday life, or where very low
educational levels pose greater challenges to objective cognitive assessment.
Comorbidity
Most individuals with Alzheimer’s disease are elderly and have multiple
medical conditions
that can complicate diagnosis and influence the clinical course. Major or mild
NCD due to Alzheimer’s disease commonly co-occurs with cerebrovascular
disease, which contributes to the clinical picture.
Major or Mild Vascular Neurocognitive
Disorder
A. The criteria are met for major or mild neurocognitive disorder.
B. The clinical features are consistent with a vascular etiology, as suggested by
either of the following:
1. Onset of the cognitive deficits is temporally related to one or more
cerebrovascular events.
2. Evidence for decline is prominent in complex attention (including processing
speed) and frontal-executive function.
C. There is evidence of the presence of cerebrovascular disease from history,
physical examination, and/or neuroimaging considered sufficient to account for the
neurocognitive deficits.
D. The symptoms are not better explained by another brain disease or systemic
disorder.
..
Probable vascular neurocognitive disorder is diagnosed if one of the following is
present; otherwise possible vascular neurocognitive disorder should be diagnosed:
1. Clinical criteria are supported by neuroimaging evidence of significant
parenchymal injury attributed to cerebrovascular disease (neuroimaging-
supported).
2. The neurocognitive syndrome is temporally related to one or more documented
cerebrovascular events.
3. Both clinical and genetic (e.g., cerebral autosomal dominant arteriopathy with
subcortical infarcts and leukoencephalopathy) evidence of cerebrovascular disease
is present.
Possible vascular neurocognitive disorder is diagnosed if the clinical criteria are
met but neuroimaging is not available and the temporal relationship of the
neurocognitive syndrome with one or more cerebrovascular events is not
established.
..
Diagnostic Features
The diagnosis of major or mild vascular neurocognitive disorder (NCD)
requires the establishment of an NCD (Criterion A) and the
determination that cerebrovascular disease is the dominant if not
exclusive pathology that accounts for the cognitive deficits (Criteria B
and C). Vascular etiology may range from large vessel stroke to
microvascular disease; the presentation is therefore very
heterogeneous, stemming from the types of vascular lesions and their
extent and location. The lesions may be focal, multifocal, or diffuse and
occur in various combinations.
...
Associated Features Supporting Diagnosis
• A neurological assessment often reveals history of stroke and/or
transient ischemic episodes, and signs indicative of brain infarctions.
• Also commonly associated are personality and mood changes, abulia,
depression, and emotional libity.
• The development of late onset depressive symptoms accompanied by
psychomotor slowing and executive dysfunction is a common
presentation among older adults with progressive small vessel
ischemic disease (“vascular depression”).
..
• Major or mild vascular NCD is the second most common cause of NCD
after Alzheimer’s disease.
• In the United States, population prevalence estimates for vascular
dementia range from 0.2% in the 65–70 years age group to 16% in
individuals 80 years and older.
• Within 3 months following stroke, 20%–30% of individuals are
diagnosed with dementia.
 t
Risk and Prognostic Factors
Environmental. The neurocognitive outcomes of vascular brain injury are
influenced by neuroplasticity factors such as education, physical exercise,
and mental activity.
Genetic and physiological. The major risk factors for major or mild vascular
NCD are the same as those for cerebrovascular disease, including
hypertension, diabetes, smoking, obesity, high cholesterol levels, high
homocysteine levels, other risk factors for atherosclerosis and
arteriolosclerosis, atrial fibrillation, and other conditions increasing the risk
of cerebral emboli.
• Cerebral amyloid angiopathy is an important risk factor in which amyloid
deposits occur within arterial vessels. Another key risk factor is the
hereditary condition cerebral autosomal.
Major or Mild Neurocognitive Disorder
Due to Another Medical Condition
Diagnostic Criteria
A. The criteria are met for major or mild neurocognitive disorder.
B. There is evidence from the history, physical examination, or laboratory findings that the
neurocognitive disorder is the pathophysiological consequence of another medical
condition.
C. The cognitive deficits are not better explained by another mental disorder or another
specific neurocognitive disorder (e.g., Alzheimer’s disease, HIV infection).
Diagnostic Features
A number of other medical conditions can cause neurocognitive disorders (NCDs). These
conditions include structural lesions (e.g., primary or secondary brain tumors, subdural
hematoma, slowly progressive or normal-pressure hydrocephalus), hypoxia related to
hypoperfusion from heart failure, endocrine conditions (e.g., hypothyroidism, hypercalce-
mia, hypoglycemia), nutritional conditions (e.g., deficiencies of thiamine or niacin), other
infectious conditions (e.g., neutrophil's, cryptococcosis), immune disorders (e.g., temporal
arteritis, systemic lupus erythematosus), hepatic or renal failure, metabolic conditions
(e.g., Kufs’ disease, adrenoleukodystrophy, metachromatic leukodystrophy, other storage
diseases of adulthood and childhood), and other neurological conditions (e.g., epilepsy,
multiple sclerosis.
 ..
Development and Course
Typically the course of the NCD progresses in a manner that is commensurate with
progression of the underlying medical disorder. In circumstances where the medical disorder
is treatable (e.g., hypothyroidism), the neurocognitive deficit may improve or at least not
progress. When the medical condition has a deteriorative course (e.g., secondary
progressive multiple sclerosis), the neurocognitive deficits will progress along with the
temporal course of illness.
Diagnostic Markers
Associated physical examination and laboratory findings and other clinical features depend
on the nature and severity of the medical condition.
Differential Diagnosis
Other major or mild neurocognitive disorder. The presence of an attributable medical
condition does not entirely exclude the possibility of another major or mild NCD. If cognitive
deficits persist following successful treatment of an associated medical condition, then
another etiology may be responsible for the cognitive decline.
Dementia due to multiple etiologies
Diagnostic Criteria
A. The criteria are met for major or mild neurocognitive disorder.
B. There is evidence from the history, physical examination, or
laboratory findings that the neurocognitive disorder is the
pathophysiological consequence of more than one etiological process,
excluding substances (e.g., neurocognitive disorder due to Alzheimer’s
disease with subsequent development of vascular neurocognitive
disorder).
C. The cognitive deficits are not better explained by another mental
disorder and do not occur exclusively during the course of a delirium.
 ..
Coding note: For major neurocognitive disorder due to multiple etiologies, with
behavioral disturbance, code 294.11 (F02.81); for major neurocognitive disorder
due to multiple etiologies, without behavioral disturbance, code 294.10 (F02.80).
All of the etiological medical conditions (with the exception of vascular disease)
should be coded and listed separately immediately before major neurocognitive
disorder due to multiple etiologies (e.g., 331.0 [G30.9] Alzheimer’s disease; 331.82
[G31.83] Lewy body disease; 294.11 [F02.81] major neurocognitive disorder due to
multiple etiologies, with behavioral disturbance).
This category is included to cover the clinical presentation of a neurocognitive
disorder (NCD) for which there is evidence that multiple medical conditions have
played a probable role in the development of the NCD. In addition to evidence
indicative of the presence of multiple medical conditions that are known to cause
NCD (i.e., findings from the history and physical examination, and laboratory
findings), it may be helpful to refer to the diagnostic criteria and text for the various
medical etiologies (e.g., NCD due to Parkinson’s disease) for more informationon
establishing the etiological connection for that particular medical condition.