PARAPHILIC DISORDERS, SEXUAL DISFUNCTION, AND VOYEURISTIC DISORDER

GENDER DYSPHORIA
Diagnostic Criteria
Paraphilic Disorder
A. Over a period of at least 6 months, recurrent and
The paraphilias include a variety of sexual behaviors that intense sexual arousal from observing an
most people reject as distasteful, unusual, or abnormal: unsuspecting person who is naked, in the process
They involve something other than genital sex with a of disrobing, or engaging in sexual activity, as
normal, consenting adult. manifested by fantasies, urges, or behaviors.
B. The person has acted on these sexual urges with a
A paraphilic disorder is diagnosed when a person feels
nonconsenting person, or the sexual urges or
distressed or is impaired by such behavior. Nearly all of
fantasies cause clinically significant distress or
then are practiced largely, perhaps exclusively, by males.
impairment in social, occupational, or other
There are many additional paraphilias in the world; those important areas of functioning.
listed in DSM-5 are more common and, in some cases, C. The individual experiencing the arousal and/or
have greater impact. acting on the urges is at least 18 years of age.

A paraphilia is a necessary but not sufficient condition for EXHIBITIONISTIC DISORDER

having a paraphilic disorder, and a paraphilia by itself does
Diagnostic Criteria
not necessarily justify or require clinical intervention.
A. Over a period of at least 6 months, recurrent and
The diagnosis of paraphilic disorder should be reserved for
intense sexual arousal from the exposure of one’s
individuals who meet both Criteria A and B. If an individual
genital to an unsuspecting person, as manifest by
meets Criterion A and B for a particular paraphilia, then
fantasies, urges, or behaviors.
the individual may be said to have that paraphilia but not
B. The person has acted on these sexual urges with a
a paraphilic disorder.
nonconsenting person, or the sexual urges or
A paraphilia that is currently causing distress or fantasies cause clinically significant distress or
impairment to the individual or a paraphilia whose impairment in social, occupational, or other
satisfaction has entailed personal harm, or risk of harm, to important areas of functioning.
others.
Specify whether:
Classification Schemes:
• Sexually aroused by exposing genitals to
1. Anomalous activity preference: prepubertal children.
1.1. Courtship Disorder – resemble distorted • Sexually aroused by exposing genitals to physically
components of human courtship behavior. mature individuals.
• Voyeuristic Disorder • Sexually aroused by exposing genitals to
• Exhibitionistic Disorder prepubertal children and physically mature
• Frotteuristic Disorder individuals.
2. Anomalous target preference:
NOTE: The thrilling element of risk is an important part of
2.1. Algolagnic Disorder – involve pain and
exhibitionistic disorder. To meet diagnosis for
suffering.
exhibitionistic disorder, the behavior must occur
• Directed to other humans –
repeatedly and be compulsive or out of control.
Pedophilic Disorder
• Directed elsewhere – Fetishistic FROTTEURISTIC DISORDER
Disorder and Transvestic Disorder
Diagnostic Criteria

A. Over a period of at least 6 months, recurrent and

intense sexual arousal from touching or rubbing
against a nonconsenting person, as manifested by
fantasies, urges, or behaviors.
B. The person has acted on these sexual urges with a
nonconsenting person, or the sexual urges or
fantasies cause clinically significant distress or
impairment in social, occupations, or other
important areas of functioning.
SEXUAL MASOCHISM DISORDER Specify if:

Diagnostic Criteria • Sexually attracted to males

• Sexually attracted to females
A. Over a period of at least 6 months, recurrent and
• Sexually attracted to both
intense sexual arousal from the act of being
humiliated, beaten, bound, or otherwise made to Specify if:
suffer, as manifested by fantasies, urges, or
behaviors. • Limited to incest
B. The fantasies, sexual urges, or behaviors cause One aspect of the criteria that can be confusing is the
clinically significant distress or impairment in required 5-year age difference between perpetrator and
social, occupational, or other important areas of victim. As the Coding Notes indicate, a 15-year-old having
functioning. a sexual relationship with someone of any age would not
Specify if: be diagnosed as having pedophilic disorder. Someone who
is 20 having an affair with a 14-or 15-year-old, however,
• With asphyxiophilia: If the individual engages in would.
the practice of achieving sexual arousal related to
restriction of breathing. If we interpret strictly what DSM-5 says, we won’t be
making the diagnosis in someone whose victim has begun
SEXUAL SADISM DISORDER to develop sexually. This has caused a lot of heartburn
among clinicians as well as some members of the relevant
Diagnostic Criteria
DSM-5 committee, who worry that by maintaining the
A. Over a period of at least 6 months, recurrent and current definition DSM-5 depathologizes men who prefer
intense sexual arousal from the psychological or certain children 13 and under who are not prepubertal.
physical suffering of another person, as
PEDOPHILIC DISORDER: Diagnostic Criteria
manifested by fantasies, urges, or behaviors.
B. The person has acted on these sexual urges with a • If the children are the person’s relatives, the
nonconsenting person, or the sexual urges or pedophilia takes the form of incest.
fantasies cause clinically significant distress or • Although pedophilia and incest have much in
impairment in social, occupational, or other common, victims of pedophilic disorder tend to
important areas of functioning. be young children, and victims of incest tend to be
PEDOPHILIC DISORDER the girls beginning to mature physically. By using
penile strain gauge measures, demonstrated that
Diagnostic Criteria incestuous males are, in general, more aroused by
adult women than are males with pedophilic, who
A. Over a period of at least 6 months, recurrent,
tend to focus exclusive on children. Thus,
intense sexually arousing fantasies, sexual urges,
incestuous relations may have more to do with
or behaviors involving sexual activity with a
availability and interpersonal issues ongoing in
prepubescent child or children (generally age 13
the family than pedophilia.
years or younger).
• But most child molesters are not physically
B. The person has acted on these sexual urges, or
abusive. Rarely is a child physically forced or
other sexual urges or fantasies cause marked
injured. From the molester’s perspective, no harm
distress or interpersonal difficulty.
is done because there is no physical force or
C. The individual is at least age 16 years and at least
threats.
5 years older than the child or children in Criterion
A. • Child molesters often rationalize their behavior as
“loving” the child or teaching the child useful
NOTE: Do not include an individual in late adolescence lessons about sexuality. The child molester almost
involved in an ongoing sexual relationship with a 12- or 13- never considers the psychological damage the
year-old. victim suffers, yet these interactions often destroy
the child’s trust and ability to share intimacy.
Specify type:
• Child molesters rarely gauge their power over the
• Exclusive type (attracted only to children) children, who may participate in the molestation
• Nonexclusive type without protest yet be frightened and unwilling.
FETISHISTIC DISORDER If sexual arousal is primarily focused on the clothing itself
the diagnostic criteria require a specification “with
Diagnostic Criteria
fetishism”
A. Over a period of at least 6 months, recurrent and
Another specifier for transvestism describes a pattern of
intense sexual arousal from the use of nonliving
sexual arousal associated not with clothing itself but
objects or a highly specific focus on a nongenital
rather with thoughts or images of oneself as a female.
body parts, as manifested by fantasies, urges, or
behaviors. OTHER SPECIFIED PARAPHILIC DISORDER
B. The fantasies, sexual urges, or behaviors cause
Other Specified Paraphilic Disorder
clinically significant distress or impairment in
social, occupational, or other important areas of This category applies to presentations in which symptoms
functioning. characteristics of a paraphilic disorder that cause clinically
C. The fetish objects are not limited to articles of significant distress or impairment in social, occupational,
clothing used in cross-dressing (as in transvestic or other important areas of functioning predominate but
disorder) or devices specifically designed for the do not meet the full criteria for any of the disorders in the
purpose of tactile genital stimulation (e.g., a paraphilic disorders diagnostic class. The other specified
vibrator). paraphilic disorder category is used in situations in which
the clinician chooses to communicate the specific reason
Specify if:
that the presentation does not meet the criteria for any
• Body Parts specific paraphilic disorder.
• Nonliving Objects
Presentations that can be specified using the “other
• Other
specified” designation include, but are not limited to,
A person is sexually attracted to nonliving objects. There recurrent and intense sexual arousal involving zoophilia
are almost as many types of fetishes as there are objects, (animals), coprophili (feces), or necrophlia (corpses) that
although women’s undergarments and shoes are popular. has been present for at least 6 months and causes marked
distress or impairment in social, occupational, or other
Fetishistic arousal is associated with: important areas of functioning.
1. An inanimate object SEXUAL DYSFUNCTIONS
2. A source of specific tactile stimulation, such as
rubber, particularly clothing made out of rubber.
Shiny black plastic is also used. Most of the
person’s sexual fantasies, urges, and desires focus
on this object.
3. A third source of attraction (some called
partialism) is a part of the body, such as the foot,
buttocks, or hair.

TRANSVESTIC DISORDER

Diagnostic Criteria

A. Over a period of at least 6 months, recurrent and

intense sexual arousal from cross-dressing, as
manifested by fantasies, urges, or behaviors.
B. The fantasies, sexual urges, or behaviors cause The different stages in the sexual response cycle, three of
clinically significant distress or impairment in them-desire, arousal, and orgasm (see Figure 10.2)-are
social, occupational, or other important areas of each associated with specific sexual dysfunctions. In
functioning. addition, pain can become associated with sexual
Specify if: functioning in women, which leads to an additional
dysfunction
• With fetishism
• With autogynephilia
Type of Men Women Schreiner-Engel and Schiavi (1986) noted that patients
Disorder with this disorder rarely have sexual fantasies, seldom
Male hypoactive Female sexual masturbate (35% of the women and 52% of the men never
sexual desire interest/arousal masturbated, and most of the rest in their sample
Desire
disorder (little or no disorder (little or no masturbated no more than once a month), and attempt
desire to have sex) desire to have sex) intercourse once a month or less.
Erectile disorder Female sexual
(difficulty attaining interest/arousal TABLE 10.1 Criteria for Male Hypoactive Desire
Arousal
or maintaining disorder (little or no Disorder
erections) desire to have sex)
Delayed Female orgasmic A. Persistently or recurrently deficient (or absent)
ejaculation; disorder sexual/ erotic thoughts or fantasies and desire
Orgasm
premature (Early) for sexual activity. The judgment of deficiency is
ejaculation made by the clinician, taking into account
Genito-pelvic factors that affect sexual functioning, such as
pain/penetration age and general and sociocultural contexts of
disorder (pain, the person's life.
anxiety, and tension B. The symptoms in Criterion A have persisted for
associated with a minimum duration of approximately 6
Pain
sexual activity; months.
vaginismus, i.e., C. The symptoms in Criterion A cause clinically
muscle spasms in the significant distress in the individual.
vagina that interfere D. The sexual dysfunction is not better explained
with penetration by a non- sexual mental disorder or as a
consequence of severe relationship distress or
other significant stressors and is not
1. Lifelong refers to a chronic condition that is present attributable to the effects of a
during a person's entire sexual life. substance/medication or another medical
condition.
2. Acquired refers to a disorder that begins after sexual
Specify whether:
activity has been relatively normal.
• Lifelong Type
------------------------------------- • Acquired Type
Specify whether:
1. Generalized occurs every time the individual attempts • Generalized Type
sex. • Situational Type
2. Situational occurs with some partners or at certain
times but not with other partners or at other times. In female low sexual interest is almost always
accompanied by a diminished ability to become excited or
In the context of healthy relationship, occasional or partial
aroused by erotic cues or sexual activity. Thus, deficits in
sexual dysfunctions are easily accommodated. But this
interest or the ability to become aroused in women is
does raise problems for diagnosing sexual dysfunctions.
combined in a disorder.
Should a sexual problem be identified as a diagnosis when
In many clinics, it is the most common presenting
dysfunction clearly is present but the person is not
complaint of women; men present more often with
distressed about it?
erectile dysfunction.
In DSM-5 the symptoms must clearly cause clinically
TABLE 10.2 Criteria for Female Sexual Interest/Arousal
significant distress in the individual.
Disorder
SEXUAL DESIRE DISORDERS
A. Lack of, or significantly reduced, sexual
Characterized by little or no interest in sex that is causing interest/arousal. as manifested by at least three of the
significant distress in the individual. following
1. Absent/reduced interest in sexual activity.
Problems of sexual interest or desire used to be
2. Absent reduced sexual/erotic thoughts or
considered marital rather than sexual difficulties. Since fantasies.
the recognition in the late 1980s of low sexual desire as a 3. No/reduced initiation of sexual activity, and
distinct disorder, however, increasing numbers of couples typically unreceptive to a pander 's attempts to
present to sex therapy clinics with one of the partners initiate.
reporting this problem.
 4. Absent/reduced sexual excitement pleasure STATISTICS
during sexual activity in almost all or all
(approximately 75%- 100%) sexual encounters • The problem here is not desire. Many males with
(in identified situational contexts or, if erectile dysfunction have frequent sexual urges
generalized, in all contexts). and fantasies and a strong desire to have sex.
5. Absent reduced sexual interest arousal in Their problem is in becoming physically aroused.
response to any internal or external • For females who are also likely to have low
sexual/erotic cues (e.g. written, verbal, visual). interest, deficits in arousal are reflected in an
6. Absent reduced genital or non-genital inability to achieve or maintain adequate
sensations during sexual activity in almost all or lubrication.
all approximately 75%-100%) sexual • A man typically feels more impaired by his
encounters (in identified situational contexts
problem than a woman does by hers. Inability to
or, if generalized, in all contexts).
achieve and maintain an erection makes
B. The symptoms in Criterion A have persisted for a
minimum duration of approximately 6 months. intercourse difficult or impossible. Women who
C. The symptoms in Criterion A cause clinically are unable to achieve vaginal lubrication,
significant distress in the individual. however, may be able to compensate by using a
D. The sexual dysfunction is not better explained by a commercial lubricant.
nonsexual mental disorder or as a consequence of • The prevalence of erectile dysfunction is
severe relationship distress or other significant startlingly high and increases with age.
stressors and is not attributable to the effects of a • Erectile disorder is easily the most common
substance medication or another medical condition. problem for which men seek help, accounting for
Specify Type: 50% or more of the men referred to specialists for
• Lifelong Type sexual problems.
• Acquired Type
Specify Type: Some impairment is present in approximately 40% of men
• Generalized Type in their 40s and 70% of men in their 70s.
• Situational Type
ORGASM DISORDERS: Diagnostic Criteria

ERECTILE DYSFUNCTION: Diagnostic Criteria An inability to achieve an orgasm despite adequate sexual
desire and arousal is commonly seen in women and less
A. At least one of the three following symptoms must commonly seen in men.
be experienced on almost all or all (approximately
75%-100%) occasions of sexual activity (in Males who achieve orgasm only with great difficulty or not
identified situational contexts or, if generalized, in at all meet criteria for a condition called delayed
all contexts): ejaculation. In women the condition is referred to as
1. Marked difficulty in obtaining an erection female orgasmic disorder.
during sexual activity. TABLE 10.3 Criteria for Female Orgasmic Disorder
2. Marked difficulty in maintaining an
erection until the completion of sexual A. Presence of either of the following symptoms and
activity. experienced on almost all or all (approximately 75%-
3. Marked decrease in erectile rigidity. 100%) occasions of sexual activity (in identified
B. The symptoms in Criterion A have persisted for a situational contexts or, if generalized, in all contexts):
minimum duration of approximately 6 months. 1. Marked delay in, marked infrequency of, or
C. The symptoms in Criterion A cause clinically absence of orgasm.
significant distress in the individual. 2. Markedly reduced intensity of orgasmic
sensations.
D. The sexual dysfunction is not better explained by
B. The symptoms in Criterion A have persisted for a
a nonsexual mental disorder or as a consequence
minimum duration of approximately 6 months.
of severe relationship distress or other significant
C. The symptoms in Criterion A cause clinically
stressors and is not attributable to the effects of a significant distress in the individual.
substance/medication or another medical D. The sexual dysfunction is not better explained by a
condition. nonsexual mental disorder or as a consequence of
severe relationship distress or other significant
stressors and is not attributable to the effects of a
substance/ medication or another medical condition.
Specify Type:
• Lifelong Type
 • Acquired Type PREMATURE EJACULATION: Diagnostic Criteria
Specify Type:
Premature ejaculation, ejaculation that occurs well before
• Generalized Type
the man and his partner wish it to (Althof, 2006; Polonsky,
• Situational Type
2000; Wincze, 2009), defined as approximately 1 minute
after penetration in DSM5 (see DSM Table 10.4).
DELAYED EJACULATION: Diagnostic Criteria
In the U.S. survey, 21% of all men met criteria for
A. Either of the following symptoms must be premature ejaculation, making it the most common male
experienced on almost all or all occasions sexual dysfunction (Laumann et al., 1999).
(approximately 75%-100%) of partnered sexual
activity (in identified situational contexts or, if Although occasional early ejaculation is normal,
generalized, in all contexts), and without the consistent premature ejaculation appears to occur
individual desiring delay: primarily in inexperienced men with less education about
1. Marked delay inejaculation. sex (Laumann et al., 1999).
2. Marked infrequency or absence of TABLE 10.4 Criteria for Premature Ejaculation
ejaculation.
B. The symptoms in Criterion A have persisted for a A. A persistent or recurrent pattern of ejaculation
minimum duration of approximately 6 months. occurring partnered sexual activity within
C. The symptoms in Criterion A cause clinically approximately 1 minute following vaginal
significant distress in the individual. penetration and before the person wishes it.
D. The sexual dysfunction is not better explained by Note: Although the diagnosis of premature
a nonsexual mental disorder or as a consequence (early) ejaculation may be applied to individuals
of severe relationship distress or other significant engaged in nonvaginal sexual activities, specific
duration criteria have not been established for
stressors and is not attributable to the effects of a
these activities.
substance/medication or another medical
B. The symptom in Criterion A must have been
condition. present for at least 6 months and must be
STATISTICS experienced on almost all or all (approximately
75%-100%) occasions of sexual activity (in
In diagnosing this problem, it is necessary to determine identified situational contexts or, if generalized,
that the women "never or almost never" reach orgasm in all contexts).
(Wincze & Carey, 2001). This distinction is important C. The symptoms in Criterion A cause clinically
because only approximately 20% of all women reliably significant distress in the individual.
experience regular orgasms during sexual intercourse. D. The sexual dysfunction is not better explained
by a non- sexual mental disorder or as a
• "Never or almost never" inquiry is important, consequence of severe relationship distress or
along with establishing the extent of the woman's other significant stressors and is not
distress, in diagnosing orgasmic dysfunction. attributable to the effects of a
• Approximately 8% of men report having delayed substance/medication or another medical
ejaculation or none during sexual interactions. It condition.
Specify Type:
is quite possible that in many cases some men
• Lifelong Type
reach climax through alternative forms of
• Acquired Type
stimulation and that this condition is
Specify Type:
accommodated by the couple.
• Generalized Type
• Occasionally men suffer from retrograde • Situational Type
ejaculation, in which ejaculatory fluids travel
backward into the bladder rather than forward.
This phenomenon is almost always caused by the PAIN DISORDER
effects of certain drugs or a coexisting medical
Diagnostic Criteria
condition and should not be confused with
delayed ejaculation. A sexual dysfunction specific to women refers to
difficulties with penetration during attempted intercourse
or significant pain during intercourse.

For some women, sexual desire is present, and arousal

and orgasm are easily attained, but the pain during
attempted intercourse is so severe that sexual behavior is 4. A strong desire to be of the other gender (or some
disrupted. alternative gender different from one's assigned
gender).
In other cases, severe anxiety or even panic attacks may
5. Strong desire to be treated as the other gender (or
occur in anticipation of possible pain during intercourse.
some alternative gender different from one's
Women report sensations of “ripping, burning, or tearing assigned gender).
during attempted intercourse” 6. A strong conviction that one has the typical
feelings and reactions of the other gender (or
TABLE 10.5 Criteria for Genito-Pelvic Pain/Penetration some alternative gender different from one's
Disorder assigned gender).
A. Persistent or recurrent difficulties with one (or more) B. The condition is associated with clinically significant
of the following: distress or impairment in social, school, or other
1. Vaginal penetration during intercourse. important areas of functioning.
2. Marked vulvoginal or pelvic pain during
vaginal intercourse or penetration attempts. Note: The term gender dysphoria focuses on one's
3. Marked fear or anxiety about vulvovaginal or discomfort as the problem, rather than identity.
pelvic pain in anticipation of, during, or as a
result of vaginal penetration.
4. Marked tensing or tightening of the pelvic
floor muscles during attempted vaginal
penetration.
B. The symptoms in Criterion A have persisted for a
minimum duration of approximately 6 months.
C. The symptoms in Criterion A cause clinically
significant distress in the individual.
D. The sexual dysfunction is not better explained by a
non-sexual mental disorder or as a consequence of
severe relationship distress or other significant
stressors and is not attribute to the effects of a
substance/medication or another medical condition.
Specify Type:
• Lifelong Type
• Acquired Type

GENDER DYSPHORIA

In Adolescents and Adults:

A. A marked incongruence between one's

experienced/expressed gender and assigned gender, of at
least 6 months duration, as manifested by at least two of
the following:

1. A marked incongruence between one's

experienced/expressed gender and primary
and/or secondary sex characteristics (or in young
adolescents, the anticipated secondary sex
characteristics).
2. A strong desire to be rid of one's primary and/or
secondary sex characteristics because of a marked
incongruence with one's experienced/expressed
gender (or in young adolescents, a desire to
prevent the development of the anticipated
secondary sex characteristics).
3. A strong desire for the primary and/or secondary
sex characteristics of the other gender.
 SCHIZOPHRENIA Clinical Description of Schizophrenia: Positive Symptoms

The symptoms under this category are described as

CLINICAL DESCRIPTION excessive and distorted. Mostly, acute episodes of
● Schizophrenia is a disorder characterized by schizophrenia are characterized by these.
disturbances in thought, emotion, and behavior:
1. Delusion – beliefs contrary to reality, which are firmly
disordered thinking, faulty perception and
held in spite of disconfirming evidence. It may take several
attention, lack of / inappropriate emotional
expressiveness, and disturbances in movement other forms as well, including the following:
and behavior. 1.1. Thought insertion – person may believe that
thoughts that are not his or her own have been
● Continuous signs of the disturbance placed in his or her mind by an external source.
persist for at least 6 months. This 6-month period
must include at least 1 month of symptoms (or 1.2. Thought broadcasting – a person may believe
less if successfully treated) that meet the first that his or her thoughts are broadcast or transmitted
criterion (i.e., active-phase symptoms) and may so that others know what he or she is thinking.
include periods of prodromal or residual
symptoms. During these prodromal or residual 1.3. A person may believe that an external force
periods, the signs of the disturbance may be controls his or her feelings or behaviors.
manifested by only negative symptoms or by two
or more symptoms listed in the first criterion 1.4. Grandiose delusions an exaggerated sense of his
present in an attenuated form (e.g., odd beliefs, or her own importance, power, knowledge, or
unusual perceptual experiences). identity.

1.5. Ideas of reference Incorporating unimportant

● People with schizophrenia typically have a
events within a delusional framework and reading
number of acute episodes of their symptoms and
personal significance into the trivial activities of
less severe but still debilitating symptoms
between episodes. others.

1.6. Persecutory delusion- belief that other people

● We still have a long way to go before we fully are planning to persecute or plot against him or her.
understand the multiple factors that trigger
schizophrenia and have treatments that are both Nonetheless, delusions are not limited to the diagnosis of
effective and free of unpleasant side effects. schizophrenia. It can be observed as well in people with
bipolar disorder, depression, and delusional disorder.
● People with schizophrenia can differ from one
another quite a bit, as there is an extensive range 2. Hallucination – these are sensory experiences in the
of symptoms. Likewise, there is no single absence of any relevant stimulation from the
symptom must be present to be diagnosed with environment. The more common type is auditory than
schizophrenia. visual hallucination, in which 74% of the sample in the
study of people with schizophrenia reported having this
● The different symptoms were divided into two type of hallucination.
categories: positive and negative symptoms. After
that, the positive symptom category was further • The form of auditory hallucination differs. There
divided into positive symptoms and disorganized were reports of hearing one's own thoughts
symptoms. spoken by another voice, hearing voices that are
arguing, and commenting on own behavior.
Table 9.1 Summary of the Major According to Copolov, Mackinnon, and Trauer
Symptom Domains in Schizophrenia (2004), hallucinations that were longer, louder,
Positive Symptoms: Delusion and Hallucination more frequent, and experienced in the third
person are more unpleasant than those coming
Negative Symptoms: Avolition, Alogia, Anhedonia, from a known person.
Blunted Affect, Asociality
How auditory hallucination happens?
Disorganized Symptoms: Disorganized Behavior and
Disorganized Speech People with auditory hallucinations misattribute their own
voice as being someone else's voice. Neuroimaging
studies found that there is greater activation in Broca's
area (the speech production area of the brain) for these
people.
But why do they misattribute their own thought? 4. Blunted Affect – refers to a lack of outward
expression of emotion. In particular, they may
There may be a problem in the connections between the
stare vacantly, the muscles of the face are
frontal lobe areas that enable the production of speech
motionless, and the eyes are lifeless. However,
and the temporal lobe areas that enable the
refers only to the outward expression of emotion,
understanding of speech. But other studies also found
not to the patient's inner experience, which is not
greater activation in speech processing and understanding
Impoverished at all.
in the temporal lobes.
5. Alogia – refers to a significant reduction in the
CLINICAL DESCRIPTIONS OF SCHIZOPHRENIA: Negative amount of speech. A person may answer a
Symptoms question with one or two words and will not be
likely to elaborate on an answer with additional
It includes avolition, asociality, anhedonia, blunted affect, detail.
and alogia. These symptoms tend to endure beyond an
acute episode and have profound effects on the lives of CLINICAL DESCRIPTIONS OF SCHIZOPHRENIA:
people with schizophrenia. Furthermore, the presence of Disorganized Symptoms
negative symptoms is a strong predictor of a poor
1. Disorganized Speech (Formal Thought Disorder) –
prognosis.
refers to problems in organizing ideas and in speaking.
The symptoms below can be grouped into two: experience Disorganization in speech may be caused by lose-
domain (avolition, asociality, and anhedonia) and association or derailment (i.e., the person may be more
expression (blunted affect and alogia): successful in communicating with a listener but has
difficulty sticking to one topic).
1. Avolition – refers to a lack of motivation and a
seeming lack of interest in or an inability to persist • It would seem logical to expect disorganized
in routine activities. People with this symptom speech to be associated with problems in
often spend time sitting around doing nothing due language production, but this does not appear to
to a drop in interest in usual activities. be the case. Instead, disorganized speech is
2. Asocialty – severe impairment in social associated with problems in what is called
relationships. When around others, people with executive functioning-problem-solving, planning,
this symptom may interact only superficially and and making associations between thinking and
briefly and appear aloof or indifferent to social feeling.
interaction.
2. Disorganized Behavior – people showing this symptom
3. Anhedonia – a loss of interest in or a reported
may lose the ability to organize their behavior and make it
lessening of the experience of pleasure. There are
conform to community standards. For instance, go into
two types of pleasure experiences:
inexplicable bouts of agitation, dress in unusual clothes,
3.1. Consummatory Pleasure – the amount of
act in a childlike or silly manner, hoard food, or collect
pleasure experienced in the moment or in
garbage.
the presence of something pleasurable.
For example, the amount of pleasure you CLINICAL DESCRIPTIONS OF SCHIZOPHRENIA: Movement
experience as you are eating a good meal Symptoms
is a consummatory pleasure.
There is another symptom that does not fit into the
3.2. Anticipatory Pleasure – the amount of
previous categories but is an important part of the DSM
expected or anticipated pleasure from
criteria for schizophrenia: Grossly abnormal psychomotor
future events or activities. The anhedonia
behavior refers to disturbances in movement behavior.
deficit in schizophrenia appears to be in
this type of pleasure. People with • Catatonia, for example, can be described as
schizophrenia appear to still feel pleasure gestures that are repeated in a peculiar manner,
in actual/present activities. For example, and an unusual increase in their overall level of
the amount of pleasure you expect to activity (e.g., excitement, wild flailing of the limbs,
receive after graduating from college. and great expenditure of energy similar to mania).
• People with schizophrenia • On the other end, catatonic immobility is
appear to have a deficit in described as an unusual posture and maintenance
anticipatory pleasure but not of them for very long periods of time.
consummatory pleasure.
 • Catatonia is seldom seen today because A. the presence of one (or more) delusions with a
medications work effectively on these disturbed duration of 1 month or longer.
motor processes. But Boyle (1991) argued that B. Criterion A for schizophrenia has never been met.
the high prevalence of it before reflected the C. Apart from the impact of the delusion(s) or its
misdiagnosis of encophalitis lethargica (sleeping ramifications, functioning is not markedly
sickness) as catatonia. impaired, and behavior is not obviously bizarre or
odd.
CLINICAL DESCRIPTIONS OF SCHIZOPHRENIA: Other
D. If manic or major depressive episodes have
Psychotic Disorders
occurred, these have been brief relative to the
1. Schizophreniform Disorder – the symptoms are the duration of the delusional periods.
same as those of schizophrenia but last only from 1 to 6
DELUSIONAL SPECIFIERS
months.
Erotomanic type: This subtype applies when the central
• Numerous studies have shown that psychotic theme of the delusion is that another person is in love
patients who have been briefly ill have a much with the individual.
better chance of full recovery than those who
have been ill for 6 months or longer. Still, over half Grandiose type: This subtype applies when the central
of those diagnosed with theme of the delusion is the conviction of having some
• Schizophreniform Disorder is eventually found to great (but unrecognized) talent or insight or having made
have schizophrenia or schizoaffective disorder. some important discovery.
• The-form suffix means this: The symptoms look
Jealous type: This subtype applies when the central
like schizophrenia, which it may turn out to be.
theme of the individual's delusion is that his or her spouse
But with limited information, the careful clinician
or lover is unfaithful.
feels uncomfortable rushing into a diagnosis that
implies lifelong disability and treatment. Persecutory type: This subtype applies when the central
• If it's within 6 months and the patient is still ill, use theme of the delusion involves the individual's belief that
the specifier (provisional). Once the patient has he or she is being conspired against, cheated, spied on,
fully recovered, remove the specifier. If the followed, poisoned or drugged, maliciously maligned,
patient is still ill after 6 months, SphD can no harassed, or obstructed in the pursuit of long-term goals.
longer apply. Change the diagnosis to
Somatic type: This subtype applies when the central
schizophrenia or some other disorder.
theme of the delusion involves bodily functions or
2. Brief Psychotic Disorder – lasts from 1 day to 1 month sensations.
and is often brought on by extreme stress, such as
Mixed type: This subtype applies when no delusional
bereavement. Then, recovers completely from an episode
theme predominated.
of psychosis.
Unspecified type: This subtype applies when the
• It doesn't matter how many symptoms they have
dominant delusional belief cannot be clearly determined
had or whether they have had trouble functioning
or is not described in the specific types (e.g., referential
socially or at work. (In parallel with
delusions without a prominent persecutory or grandiose
schizophreniform disorder, any patient who
component).
remains symptomatic longer than 1 month must
be given a different diagnosis). • Typically, these delusians differ from the more
bizarre types often found in people with
3. Schizoaffective Disorder – comprises a mixture of
schizophrenia because in delusional disorder the
schizophrenia and mood disorders symptoms. The DSM- 5
imagined events could be happening but aren't
requires either a depressive or manic episode.
(for example, mistakenly believing you are being
• DSM-5 criteria for schizoaffective disorder followed); in schizophrenia, however, the
require, in addition to the presence of a mood imagined events aren't possible (for example,
disorder, delusions or hallucinations for at least 2 believing your brain waves broadcast your
weeks in the absence of prominent mood thoughts to other people around the world).
symptoms (American Psychiatric Association, • Previous versions of the DSM included a separate
2013). delusional disorder-shared psychotic disorder
(folie à deux), the condition in which an individual
4. Delusional Disorder – a persistent belief that is contrary develops delusions simply as a result of a close
to reality, in the absence of other characteristics of relationship with a delusional individual.
schizophrenia.
 ANXIETY DISORDERS specific phobia as wellthat is, there is a high
comorbidity of specific phobias.
Anxiety is defined as apprehension over an anticipated
problem. In contrast, Fear is defined as a reaction to DSM-5 CRITERIA FOR SPECIFIC PHOBIA
immediate danger. Thus, a person facing bear experiences
• Marked and disproportionate fear consistently
fear, whereas a college student concerned about the
triggered by specific objects or situations.
possibility of unemployment after graduation experiences
anxiety. • The object or situation is avoided or else endured
with intense anxiety.
Both anxiety and fear can involve arousal or sympathetic • Symptoms persist for at least 6 months.
nervous system activity. Anxiety often involves moderate
arousal (restless energy and physiological tension), and Note: The DSM-IV-TR criterion that the person recognizes
fear involves higher arousal (sweating profusely, breathing that the fear is unrealistic is not Included in DSM-5. DSM-
rapidly, and feeling an overpowering urge to run). IV-TR includes the duration criterion only for those under
age 18.
Nonetheless, anxiety and fear are significant experiences.
Fear triggers rapid changes in the sympathetic nervous Despite this array of possible phobias, in reality, specific
system that prepare the body for escape or fighting, while phobias tend to cluster around a small number of feared
anxiety increases our preparedness, to help people avoid objects and situations. The DSM categorizes specific
potentially dangerous situations, and to think through phobias according to these sources of fear. A person with
potential problems before they happen, but, according to one type of specific phobia is very likely to have another
Yerkes and Dodson (1908), anxiety, then, provides a classic type of specific phobia as well-that is, there is a high
example of a U-shaped curve with performance-an comorbidity of specific phobias.
absence of anxiety is a problem, a little anxiety is adaptive, Type of Example of the Associated
and a lot of anxiety is detrimental. Phobia Feared Object Characteristics
Snakes, Insects Generally, begins
The major anxiety disorders included in DSM- 5 are Animal
during childhood
specific phobias, social anxiety disorder, panic disorder,
Natural Storms, Heights, Generally, begins
agoraphobia, and generalized anxiety disorder. Obsessive-
Environment Water during childhood
compulsive disorder and trauma-related disorders share a Blood, Injury, Clearly runs in
good deal in common with anxiety disorders but are also Injections, or other families; profile
distinct in some important ways. Blood, invasive medical of heart rate
Injection, procedures slowing and
All anxiety disorders are associated with substantial
Injury possible fainting
decrements in the quality of life.
when facing
The anxiety disorders share excessively high or frequent feared stimulus
anxiety and tendencies to experience unusually intense Public Tends to begin
fear (except for generalized anxiety disorder). For each, transportation, either in
several criteria must be met for a DSM-5 diagnosis to be Tunnels, Bridges, childhood or in
Situational
Elevators, Flying, mid-20s.
made:
Driving, Closed
1. Symptoms must interfere with important areas of Spaces
functioning or cause marked distress. Fear of Choking, Fear
2. Symptoms are not caused by a drug or a medical of Contracting an
condition. Illness, etc.;
Other
Children’s fears of
3. The fears and anxieties are distinct from the
loud sounds, clowns,
symptoms of another anxiety disorder.
etc.
SPECIFIC PHOBIA

• It is a disproportionate fear caused by a specific SOCIAL ANXIETY DISORDER

object or situation. Despite the array of possible
It is a persistent, unrealistically Intense fear of social
phobias, in reality, specific phobias tend to cluster situations that might involve being scrutinized by, or even
around a small number of feared objects and just exposed to, unfamiliar people.
situations. The DSM categorizes specific phobias
according to these sources of fear. People diagnosed with this try to avoid situations in which
• Moreover, a person with one type of specific they might be evaluated, show signs of anxiety or behave
phobia is very likely to have another type of in embarrassing ways: public speaking, speaking up in
meetings or classes, meeting new people, and talking to FEAR AND PANIC: A panic attack is a misfire of the fear
people in authority. system-physiologically, the person experiences a level of
sympathetic nervous system arousal matching what most
DSM-5 CRITERIA FOR SOCIAL ANXIETY DISORDER
people might experience when faced with an immediate
• Marked and disproportionate fear consistently threat to life.
triggered by exposure to potential social scrutiny
Lastly, the criteria for panic disorder specify that panic
• Exposure to the trigger leads to intense anxiety attacks must be recurrent. But it is fairly common for
about being evaluated negatively people to experience a single panic attack.
• Trigger situations are avoided or else endured
with intense anxiety AGORAPHOBIA: Agoraphobia (from the Greek agora,
• Symptoms persist for at least 6 months meaning "marketplace") is defined by anxiety about
situations in which it would be embarrassing or difficult to
Note: DSM-IV-TR labels this disorder as social phobia. The escape if anxiety symptoms occurred: grocery stores,
DSM-IV-TR but not DSM-5 specifies that the person malls, churches, trains, bridges, or long road trips.
recognizes the fear is unrealistic. DSM-IV-TR includes the Therefore, they are often unable to leave their house, and
duration criterion only for those under age 18. even those who can leave do so only with great distress.
It is different from normal shyness, as people with this In the DSM-IV-TR, agoraphobias is coded as a subtype of
diagnosis avoid more social situations, feel more panic disorder but it became a separate diagnosis in DSM5
discomfort socially, and experience these symptoms for to be in line with the ICD diagnostic system that has long
longer periods of their life than people who are shy. recognized it as a separate diagnosis and with the
More so, it can range in severity from a relatively few evidence from various studies that people who had
specific fears to a more generalized host of fears. For symptoms of agoraphobia reported no symptoms of panic
example, some people might be anxious about speaking in attacks or panic disorder.
public but not in other social situations. DSM-5 CRITERIA FOR AGORAPHOBIA
PANIC DISORDER: It is characterized by frequent panic • Disproportionate and marked fear or anxiety
attacks that are unrelated to specific situations and by about at least 2 situations where it would be
worry about having more panic attacks. A panic attack is a difficult to escape or receive help in the event of
sudden attack of intense apprehension, terror, and incapacitation, embarrassing symptoms, or
feelings of impending doom, accompanied by at least four paniclike symptoms, such as being outside of the
other symptoms: shortness of breath, heart palpitations, home alone; traveling on public transportation;
nausea, upset stomach, chest pain, feelings of choking and being in open spaces such as parking lots and
smothering, dizziness, lightheadedness, feeling faint, marketplaces; being in enclosed spaces such as
sweating, chills, heat sensations, numbness or tingling shops, theaters, or cinemas; or standing in line or
sensations, and trembling. being in a crowd
Other symptoms that may occur during a panic attack • These situations consistently provoke fear or
include depersonalization (a feeling of being outside one's anxiety These situations are avoided, require the
body); derealization (a feeling of the world's not being presence of a companion, or are endured with
real), and fears of losing control, of going crazy, or even of • Intense fear or anxiety Symptoms last at least 6
dying. months

DSM-5 CRITERIA FOR PANIC DISORDER Note: DSM-IV-TR includes agoraphobia as a subtype of
panic disorder rather than as a distinct diagnosis.
• Recurrent unexpected panic attacks
• At least 1 month of concern about the possibility GENERALIZED ANXIETY DISORDER
of more attacks, worry about the con- sequences The core characteristic of people with GAD is worry; they
of an attack, or maladaptive behavioral changes are persistently worried, even about minor things.
because of the attacks.
Worry is the cognitive tendency to ponder on a problem
Commonly, people experiencing an attack have an intense and to be unable to let go of it. The worries of people with
urge to flee whatever situation they are in and it happens
very rapidly, reaching its peak intensity within 10 minutes. GAD are similar in focus to those of most people: they
worry about relationships, health, finances, and daily
hassles (Roemer, Molina, & Borkovec, 1997)-but they
worry more about these issues, and these persistent
worries interfere with daily life.
It usually begins in adolescence and persists at least for 6 Premenstrual Moved from the Depressive or
months to qualify for a diagnosis. Also, it is often chronic. Dysphoric DSM-IV Appendix physical
Disorder to the main body symptoms in the
DSM-5 CRITERIA FOR GENERALIZED ANXIETY DISORDER week before
menses
• Excessive anxiety and worry at least 50 percent of
Disruptive New category for Severe recurrent
days about a number of events or activities (e.g.,
Mood DSM-5 temper outburst
family, health, finances, work, and school)
Dysregulation and persistent
• The person finds it hard to control the worry Disorder negative mood
• The worry is sustained for at least 6 months for at least 1 year
• The anxiety and worry are associated with at least beginning before
three (or one in children) of the following: age 10.
• Restlessness or feeling keyed up or on Bipolar I Abnormally At least one
edge Disorder increased activity lifetime manic
• Easily fatigued difficulty concentrating or energy episode
or mind going blank Abnormally At least one
increased activity lifetime
• Irritability
Bipolar II or energy included hypomanic
• Muscle tension
Disorder as a required episode and one
• Sleep disturbance symptoms of major depressive
MOOD DISORDERS: DEPRESSIVE DISORDERS hypomania episode
Recurrent mood
The cardinal symptoms of depression include profound changes from
sadness and/or inability to experience pleasure. They are high to low for at
accompanied by cognitive symptoms, like negative Criteria are more least 2 years,
Cyclothymia
perception and hopelessness, and physical symptoms: specific without
lethargy, sleep disturbances, and disturbances in appetite. hypomanic or
depressive
Also, Psychomotor Retardation (slow thoughts and episodes.
movements) or Psychomotor Agitation (pacing, fidgeting,
wringing of hands) may be present. In some instances,
MAJOR DEPRESSIVE DISORDER: Diagnostic Criteria
when people become utterly dejected and hopeless,
thoughts about suicide are common. As a diagnosis, it requires 5 depressive symptoms present
for at least 2 weeks. It should include either a depressed
Some people with depression have trouble falling asleep
mood or a loss of interest and pleasure.
and staying asleep. Others find themselves sleeping for
more than 10 hours but still feeling exhausted Aside from this, additional symptoms may complete the
required number: changes in sleep, appetite,
Depressive disorders – involve depressive symptoms
concentration, feelings of worthlessness, suicidality,
Bipolar disorders – involve manic and depressive psychomotor agitation, or retardation.
symptom
DSM-5 CRITERIA FOR MAJOR DEPRESSIVE DISORDER
DSM-5
Key Changes Major Features • Sad mood or loss of pleasure in usual activities.
Diagnoses
Major Differential Five or more • At least five symptoms (counting sad mood and
Depressive diagnosis of depressive loss of pleasure):
Disorder bereavement- symptoms, • Sleeping too much or too little
related symptoms including sad • Psychomotor retardation or agitation
described in more mood or loss of • Weight loss or change in appetite
detail pleasure for 2 • Loss of energy
weeks. • Feelings of worthlessness or excessive guilt
Persistent Chronic Major Low mood and at
• Difficulty concentrating thinking, or making
Depressive Depressive least two other
decisions
Disorder Disorder and symptoms of
(Dysthymia) Dysthymia are depression and • Recurrent thoughts of death or suicide
merged into this least half of the • Symptoms are present nearly every day, most of
new diagnosis time for 2 years the day, for at least 2 weeks.
• Symptoms are distinct and more severe than a
normative response to significant loss
MAJOR DEPRESSIVE DISORDER: CHARACTERISTICS Note: DSM-IV-TR but not DSM-5 criteria specify that no
major depressive episode was present during the first 2
It is episodic because symptoms tend to be present for a
years of symptoms.
period of time and then clear.
BIPOLAR DISORDERS
It may dissipate over time, but if left untreated, it may
stretch on for 5 months or even longer. In general, manic symptoms are the defining feature of
each disorder in this category and are differentiated by
For a small percentage of people, the depression becomes
their severity and chronicity.
chronic-the person does not completely snap back to the
prior level of functioning. Some people Improve enough Moreover, its label "bipolar" originated from the
that they no longer meet the criteria for diagnosis of MDD characteristics of experiencing mania and, eventually,
but continue to experience subclinical depression for depression during their lifetime.
years.
An episode of depression is not required for a diagnosis of
It may recur! 2/3 of people with an episode of major bipolar I, but it is required for a diagnosis of bipolar II
depression will experience at least 1 more during their disorder.
lifetime (Solomon, Keller, Leon, et al., 2000). The
• Mania is a state of intense elation/irritability
separation of episodes is at least 2 months, during which
accompanied by: unusual thoughts or acts, flight
the individual is not depressed.
of Ideas (rapid shifting of topics), overly confident,
A single depressive episode may last 4 to 5 months, they are unaware of possible consequences of
although it is shorter than the very first episode. In terms decisions made, and less need to sleep. It happens
of the number of episodes. suddenly over a period of a day or two.
• Hypomania is less extreme than mania and thus
According to Judd (1997), the average number of episodes
Involves a low level of impairment, although
is 4.
changes in functioning are observable.
Experiencing an episode of depression will likely increase
DSM-5 CRITERIA FOR MANIC AND HYPOMANIC
the chance of recurrence by 16%.
EPISODES
PERSISTENT DEPRESSIVE DISORDER (DYSTHYMIA)
Distinctly elevated or irritable mood
Chronically depressed: experiencing more than half of the
Abnormally increased activity or energy
time for at least 2 years low mood or little pleasure and
having at least 2 of other symptoms of depression. At least three of the following are noticeable changed
from baseline (four if mood is irritable):
Chronicity is the primary factor distinguishing Dysthymia
from Major Depressive Disorder. • Increase in goal-directed activity or psychomotor
agitation
In Dysthymia, the absence of symptoms should occur not
• Unusual talkativeness, rapid speech
more than 2 months.
• Flight of ideas or subjective impression that
It's still dangerous if left untreated, as its average duration thoughts are racing Decreased need for sleep
was more than 5 years. • Increased self-esteem; belief that one has special
talents, powers, or abilities
DSM-5 CRITERIA FOR PERSISTENT DEPRESSIVE DISORDER
(DYSTHYMIA) • Distractibility; attention easily diverted
• Excessive involvement in activities that are likely
Depressed mood for most of the day more than half of the to have painful consequences such as reckless
time for 2 years (or 1 year for children and adolescents). spending, sexual indiscretions, or unwise business
investments
At least two of the following during that time:
• Symptoms are present most of the day, nearly
• Poor appetite or overeating every day
• Sleeping too much or too little
For a manic episode:
• Poor self-esteem
• Low energy • Symptoms last for 1 week, require hospitalization
• Trouble concentrating or making decisions or include psychosis
• Feelings of hopelessness • Symptoms cause significant distress or functional
impairment
The symptoms do not clear for more than 2 months at a
time
For a hypomanic episode: The symptoms do not clear for more than 2 months at a
time. Criteria for a major depressive manic, or hypomanic
• Symptoms last at least 4 days
episode have never been met. Symptoms cause significant
• Clear changes in functioning that are observable distress or functional impairment.
to others; but impairment is not marked • no
psychotic symptoms OBSESSIVE-COMPULSIVE DISORDER

BIPOLAR I DISORDERS Obsessive-compulsive and related disorders all share a

quality of repetitive thought as well as irresistible urges to
It includes a single episode of mania in a person's life. engage repetitively in some behavior or mental acts. But
More so, a person diagnosed with this may or may not be the focus of thought and behavior takes different forms.
experiencing current symptoms of mania.
For people with obsessive-compulsive disorder.
In fact, even someone who experienced only 1 week of Extreme fears of contamination can trigger
manic symptoms years ago is still diagnosed with bipolar I abnormally frequent handwashing,
disorder.
Some people with body dysmorphic disorder may
Even more than episodes of MDD, bipolar episodes tend spend hours a day checking on their appearance,
to recur. More than half of people with bipolar I disorder but others may avoid mirrors because they find it
experience four or more episodes. painful to consider their appearance.
For the manic episodes to be considered separate, there It is characterized by obsessions or compulsions that are
must be a symptom-free period of at least 2 months persistent and intrusive.
between them. Otherwise, one episode is seen as a
continuation of the last. Obsession – is the intrusive and recurring thoughts,
images, or impulses that are persistent and uncontrollable
REMEMBER! and that often appear irrational to the person
If a person shows only manic symptoms, it is experiencing them. The most frequent foci for obsessions
nevertheless assumed that bipolar disorder exists and include fears of contamination, sexual or aggressive
that depression episodes will eventually occur impulses, body problems, religion, and symmetry or order.

BIPOLAR II DISORDERS Symmetry there are four major types of obsessions and
each is associated with a pattern of compulsive behavior.
A milder form of bipolar disorder, wherein the required obsessions account for most obsessions (26.7%), followed
symptoms are at least one Major Depressive Episode and by "forbidden thoughts or actions" (21%), cleaning and
at least one Hypomanic Episode. contamination (15.9%), and hoarding (15.4%) (Bloch et al.,
CYCLOTHYMIC DISORDER 2008).

A second chronic mood disorder characterized by 2 years It is characterized by obsessions or compulsions that are
of mild symptoms of depression alternating with mild persistent and intrusive.
symptoms of mania, although these do not reach the Compulsion – the repetitive, clearly excessive behaviors
severity of full-blown episodes, they are still impairing. or mental acts that the person feels driven to perform to
Individuals with cyclothymic disorder tend to be in one reduce the anxiety caused by obsessive thoughts or to
mood state or the other for years with relatively few prevent some calamity from occurring.
periods of neutral (or euthymic) mood. Certain kinds of obsessions are strongly associated with
People with cyclothymia should be treated because of certain kinds of rituals. Many are logical, such as
their increased risk of developing more severe bipolar I or repeatedly checking the stove to see whether you turned
bipolar II disorder. it off, but severe cases can be illogical. For example,
Richard thought that if he did not eat in a certain way he
DSM-5 CRITERIA FOR CYCLOTHYMIC DISORDER FOR AT might become possessed.
LEAST 2 YEARS (OR 1 YEAR IN CHILDREN OR
ADOLESCENTS): *On rare occasions, patients, particularly children, will
present with compulsions, but few or no identifiable
• Numerous periods with hypomanic symptoms obsessions.
that do not meet criteria for a hypomanic episode
• Numerous periods with depressive symptoms
that do not meet criteria for a major depressive
episode.
 Specify if:

With good or fair insight: The individual recognizes that

obsessive-compulsive disorder beliefs are definitely or
probably not true or that they may or may not be true.

With poor insight: The individual thinks

obsessivecompulsive disorder beliefs are probably true.

With absent insight/delusional: The person is completely

convinced that obsessive-compulsive disorder beliefs are
true.

It begins either before age 10 or in late adolescence/early

adulthood. The disorder is slightly more common among
women than men, with a gender ratio of about 1.5.

The pattern of symptoms appears to be similar across

cultures. OCD is a chronic disorder-a 40-year follow-up
study of people hospitalized for OCD in the 1950s showed
that only 20 percent had recovered completely.

The obsessions or compulsions are time consuming (e.g.,

at least 1 hour per day) or cause clinically significant
distress or impairment.

It is also common for tic disorder, characterized by

The frequency with which compulsions are repeated may
involuntary movement (sudden jerking of limbs, for
be staggering (for example, a patient chewed each
example), to co-occur in patients with OCD (particularly in
mouthful of food 300 times). Commonly reported
their families).
compulsions include:
Approximately, 10% to 40% of children and adolescents
1. Pursuing cleanliness and orderliness,
with OCD also have had a tic disorder at some point. The
sometimes through elaborate rituals
obsessions in tic-related OCS are almost always related to
2. Performing repetitive, magically
symmetry.
protective acts, such as counting or
touching a body part Specify if:
3. Repetitive checking to ensure that certain
acts are carried out-for example, Tic-related: the individual has a current or post history of
returning seven or eight times in a row to tic disorder
see that lights, stove burners, or faucets Some studies seem to suggest that a chronic tic
were turned off, windows fastened, and disorder may reduce patients’ response to
doors locked. antidepressant medications (though not to CBT),
Lastly, in one study, 78 percent of people with and that antipsychotic drugs may help.
compulsions viewed their rituals as "rather silly or absurd" DSM-5 CRITERIA FOR OBSESSIVE-COMPULSIVE
even though they were unable to stop performing them DISORDER
(Stern, 1978).
Obsessions are defined by: Recurrent, intrusive,
One feature that helps classify patients with OCD is their persistent, unwanted thoughts, urges, or images The
degree of insight. Most patients are pretty well aware that person tries to ignore, suppress, or neutralize the
their behavior is odd or peculiar, in fact, they are often thoughts, urges, or images
embarrassed by it and try to hide it. But others- perhaps
10-25% of all patients with OCD-either have never Compulsions are defined by: Repetitive behaviors or
recognized the irrationality of their behavior or have now thoughts that the person feels compelled to perform to
to some degree lost that insight. A few patients have so prevent distress or a dreaded event.
little insight that they are actually delusional. Note that The person feels driven to perform the repetitive
children often don't have the experience to judge the behaviors or thoughts in response to obsessions or
reasonableness of their own behavior; therefore, insight according to rigid rules.
specifiers often don't apply to them.
BODY DYSMORPHIC DISORDER DSM-5 CRITERIA FOR BODY DYSMORPHIC DISORDER

It is a preoccupation with one or more perceived or • Preoccupation with one or more perceived
exaggerated defects in their appearance. defects in appearance.
• The person has performed repetitive behaviors or
Women tend to focus on their skin (like Joann in the
mental acts (e.g., mirror checking, seeking
Clinical Case on the next page), hips, breasts, and legs,
reassurance, or excessive grooming) in response
whereas men are more likely to focus on their height,
to the appearance concerns.
penis size, or body hair. Other men suffer from
• Preoccupation is not restricted to concerns about
preoccupation that their body is small or insufficiently
weight or body fat.
muscular, even when others would not share the same
perception (you can use the specifier "with muscle HOARDING DISORDER
dysmorphia"), which could result in often taking dieting or
weight lifting to extremes, and may misuse anabolic People diagnosed with hoarding disorder have the urge to
steroids or other drugs. acquire and tend to abhor parting with their objects, even
when there is no clear value in them. About twothirds of
The body part that becomes a focus of concern sometimes people who hoard seem to be unaware of the severity of
differs by culture, though. For example, eyelid concerns their behavior.
are more common in Japan than in Western countries.
A more common type is animal hoarding; the
Obsession: Hard to stop thinking about their accumulating number of animals often exceeds the
concerns. On average, people with BDD think person's ability to provide adequate care, shelter, and
about their appearance for 3 to 8 hours per day. food.
Compulsion: Checking their appearance in the Specify if:
mirror, comparing their appearance to that of
other people, asking others for reassurance about • With excessive acquisition – If symptoms are
their appearance, or using strategies to change accompanied by excessive collecting, buying, or
their appearance or camouflage disliked body stealing of items that are not needed or for which
areas (grooming, tanning, exercising, changing there is no space available.
clothes, and applying makeup). However, some The accrual of objects often overwhelms the person’s
try to avoid being reminded of their perceived home: the hoarding led to extreme filthy home for about
flaws by avoiding mirrors, reflective surfaces, or a third of people, characterize by overpowering odors
bright lights. from rotten food or feces. Some may no longer use the
BDD occurs slightly more often in women than in men, but appliances and other parts of the house. Likewise, family
even among women it is relatively rare, with a prevalence relationships were afflicted.
of less than 2 percent, and typically begins in late Although hoarding is more common among men that
adolescence. women, very few men seek treatment.
Unfortunately, plastic surgery does little to allay their Onset: It usually begins in childhood or early adolescence,
concerns, and many people report wanting to sue or hurt while animal hoarding often does not emerge until middle
their physicians after the surgery because they are so age or older.
disappointed.
Comorbidity: Depression, generalized anxiety disorder,
Recovery: Over an 8-year period about three-quarters of and social phobia are common among people diagnosed
people will recover from their symptoms. with hoarding. Occasionally, hoarding symptoms develop
Comorbidity: Major depressive disorder, social anxiety among people with schizophrenia or dementia. Moreover,
disorder, obsessive-compulsive disorder, substance use it is often comorbid with OCD.
disorders, and personality disorder. DSM-5 CRITERIA FOR HOARDING DISORDER
Differential: Most people with BDD are concerned about Persistent difficulty discarding or parting with possessions,
several different aspects of their appearance. When shape regardless of their actual value Perceived need to save
and weight concerns are only foci, clinicians should items Distress associated with discarding.
consider whether the symptoms are better explained by
an eating disorder. The symptoms result in the accumulation of a large
number of possessions that clutter active living spaces to
the extent that their intended use is compromised unless
others intervene.
CLINICAL DESCRIPTION OF POST-TRAUMATIC STRESS B. At least 8 of the following symptoms began or worsened
DISORDER since the trauma and lasted 3 to 31 days:

In the DSM-5, the symptoms of PTSD are grouped into four • Recurrent, involuntary, and intrusive distressing
major categories: memories of the traumatic event, or in children,
repetitive play involving aspects of the traumatic
1. Intrusively reexperiencing the traumatic event - the
event
person may have repetitive memories or
• Recurrent distressing dreams related to the
nightmares of the event, intensely upset by or show
traumatic event
marked physiological reactions to reminders of the
event. • Dissociative reactions (e.g., flashbacks) in which
2. Avoidance of stimuli associated with the event - individual feels or acts as if the traumatic event
some may try to avoid all reminders of the event. were recurring, or in children, re-enactment of
3. Signs of mood and cognitive change after the trauma during play
trauma - include the inability to remember • Intense or prolonged psychological distress or
important aspects of the event, persistently physiological reactivity at exposure to reminders of
negative cognition, blaming self or others for the traumatic event
event, pervasive negative emotions, lack of interest • Persistent inability to experience positive events
or involvement in significant activities, feeling • Altered sense of reality of one’s surroundings or
detached from others, or inability to experience oneself
positive emotions. • Inability to remember important aspect of
4. Symptoms of increased arousal and reactivity - traumatic event
include irritable or aggressive behavior, reckless or • Avoids internal/external reminders of the
self-destructive behavior, difficulty falling asleep or trauma(s)
staying asleep, difficulty concentrating, • Sleep disturbance
hypervigilance, and an exaggerated startle • Hypervigilance
response. • Irritable or aggressive behavior
Posttraumatic stress disorder (PTSD) entails an extreme • Exaggerated startle response
response to a severe stressor, Including increased anxiety, • Agitation or restlessness
avoidance of stimuli associated with the trauma, and • Problems with concentration
symptoms of increased arousal.
Criteria for Posttraumatic Stress Disorder
Diagnoses of these disorders are considered only in the
context of serious traumas; the person must have A. The person was exposed to actual or threatened
experienced or witnessed an event that involved actual or death, serious injury, or sexual violence, in one or more
of the following ways; experiencing the event
threatened death, serious injury, or sexual violation.
personally, witnessing the event in person, learning that
Clinical Description of Acute Stress Disorder Acute Stress a violent or accidental death or threat of death occurred
Disorder is diagnosed when symptoms occur between 3 to a close other, or experiencing repeated or extreme
days and 1 month after a trauma. The symptoms of ASD exposure to aversive details of the events other than
are fairly similar to those of PTSD, but the duration is through media reports.
B. At least 1 of the following Intrusion symptoms:
shorter.
• Recurrent, involuntary, and intrusive
One reason to consider this diagnosis, though, is that ASD distressing memories of the trauma, or in
does predict a higher risk of developing PTSD within 2 children, repetitive play regarding in the trauma
years. themes.
• Recurrent distressing dreams related to the
DSM-5 CRITERIA FOR ACUTE STRESS DISORDER events.
• Dissociative reactions (e.g., flashbacks) in
A. Exposure to actual or threatened death, serious injury,
which the individual feels or acts as if the
or sexual violation in one (or more) of the following ways: traumas were recurring, or in children, re-
• Experiencing the event personally, witnessing the enactment of trauma during play.
event, learning that a violent or accidental death • Intense or prolonged distress or psychological
reactivity in response to reminders of the
or threat occurred to a close other, or
traumas.
experiencing repeated or extreme exposure to
C. At least 1 of the following Avoidance symptoms:
aversive details of the event(s) other than through
• Avoids internal reminders of the traumas.
media exposure.
• Avoids external reminders of the traumas.
 D. At least 2 of the following Negative alterations in 2. Excessive anxiety, concern, or time and energy
cognition and mood: devoted to the somatic concern.
• Inability to remember an important aspect of 3. Duration of at least 6 months.
the traumas.
• Persistent and exaggerated negative beliefs or REMEMBER:
expectations about one’s self. Others, or the
• It may seem that people with somatic symptom
world.
disorder avoid some unpleasant activity or attain
• Persistently excessive blame of self or others
sympathy but actually, they are not; they
about the traumas.
experience their symptoms as completely
• Persistently negative emotional state, or in
children younger than 7, more frequent physical.
negative emotions. • Compared to the DSM-IV-TR, the DSM-5
• Markedly diminished interest or participation emphasizes more on the distress and behavior
in significant activities. accompanying somatic symptoms, rather than the
• Feeling of detachment or estrangement from number or range of somatic symptoms.
others, or in children younger than 7, social
withdrawal. DSM-5 Criteria for Somatic Symptom Disorder
• Persistent inability to experience positive • At least one somatic symptom that is distressing
emotions. or disrupts daily life
E. At least 2 of the following Alteration in arousal and
• Excessive thoughts, feelings, and behaviors
reactivity:
related to somatic symptom(s) or health
• Irritable or aggressive behavior
concerns, as indicated by at least one of the
• Reckless of self-destructive behavior
following: health-related anxiety,
• Hypervigilance
• Exaggerated startle response disproportionate and persistent concerns about
• Problems with concentration the medical seriousness of symptoms, and
• Sleep disturbance excessive time and energy devoted to health
F. The symptoms began or worsened after the traumas concerns
and continued for at least one month. • Duration of at least 6 months
G. Among children younger than 7, diagnosis requires • Specify if predominant pain
criteria A, B, E, and F, but only 1 symptom from either
category C or D. Somatic Symptom
Panic Disorder
Disorder
The person often believes The person often believes
SOMATIC SYMPTOM-RELATED DISORDERS that the symptoms are a that the symptoms are a
sign of an immediate sign of an underlying long-
Its characteristic was excessive concerns about physical threat (e.g., a heart term disease.
symptoms or health. Previously, DSM-IV-TR required that attack).
the physical symptoms had no known physical cause but, Panic patients continue to Despite numerous
in the DSM-5, it's removed for some specific disorders. believe their panic attacks assurances that they are
Hence, somatic symptom disorder includes somatic might kill them, but most healthy, they remain
symptoms regardless of whether they can be explained learn rather quickly to unconvinced and
medically. stop going to doctors or unassured.
emergency rooms.
People diagnosed with one of the disorders in this The anxieties of Concerns range much
category tend to seek frequent medical treatment at individuals with panic wider in somatic symptom
great expense, although they are often dissatisfied and disorder tend to focus on a disorders.
no medical explanation or cure can be identified. Many specific set of 10 or 15
patients become unable to work because of the severity sympathetic nervous
of their concerns. system symptoms
associated with panic
CLINICAL DESCRIPTION OF SOMATIC SYMPTOM attack.
DISORDER

The three core criteria are: CLINICAL DESCRIPTION OF ILLNESS ANXIETY DISORDER
1. One or more somatic symptoms (different body It is a preoccupation with fears of having a serious disease
parts or general pain) that are distressing or result despite having no significant somatic symptoms. These
in significant disruption in daily life. fears must lead to care-seeking or maladaptive avoidance
that persists for at least 6 months.
DSM-5 CRITERIA FOR ILLNESS ANXIETY DISORDER EPIDEMIOLOGY:

• Preoccupation with and high level of anxiety • Develops in adolescence or early adulthood.
about having or acquiring a serious disease • It may end abruptly but may return, either in the
• Excessive illness behavior (e.g., checking for signs original form or differently.
of illness, seeking reassurance) or maladaptive • Prevalent in women than men (<1%)
avoidance (e.g., avoiding medical care or ill
COMMORBIDITY: Somatic symptom disorder, dissociative
relatives)
disorders, MDD, substance use disorder, and personality
• No more than mild somatic symptoms are present
disorders.
• Not explained by other psychological disorders
• Preoccupation lasts at least 6 months TAKE NOTE!

Note: illness anxiety disorder is a new diagnosis in the In evaluating somatic symptoms, clinicians need to be
DSM-5, but it has some parallels with DSM-IV-TR diagnosis aware of potential malingering and factitious disorders.
of hypochondriasis. The DSM-IV-TR criteria for
1. Malingering: a person intentionally fakes a symptom to
hypochondriasis specify that the preoccupation must
avoid responsibility, or to achieve some goal. has a clear
continue despite medical reassurance.
potential for reward. symptoms are voluntarily controlled
The Difference Between Somatic Symptom and Illness than conversion disorder.
Anxiety Disorders.
2. Factitious Disorder: a person intentionally produces
Illness Anxiety Disorder physical or psychological symptoms to assure the role of a
patient.
• Focusing on the fear/worry about the
uncomfortable or unusual physical sensations It can be diagnosed in a person who creates symptoms in
being an indication of a serious medical condition. another person: factitious disorder imposed on another or
Munchausen Syndrome by proxy. The common aim is the
Somatic Symptom Disorder need to be regarded as an excellent parent.
• Focusing on the disabling nature of physical DSM-5 CRITERIA FOR FACTITIOUS DISORDER
symptoms without the worry that these represent
a specific illness. • Fabrication of physical or psychological
symptoms, injury or disease
Clinical Description of Conversion Disorder (Functional
• Deceptive behavior is present in the absence of
Neurological Symptom Disorder)
obvious external rewards
The person with conversion disorder suddenly develops • Behavior is not explained by another mental
neurological symptoms, but medical tests indicate that the disorder
organism and nervous system are fine. • In Factitious Disorder imposed on Self, the person
presents himself or herself to others as ill,
Common conditions:
impaired, or Injured
1. Tunnel Vision – the visual field is constricted • In Factitious Disorder imposed on another, the
2. Aphonia – loss of a voice other than whispered person fabricates symptoms in another person
speech. and then presents that person to others ill,
3. Anosmia – loss of the sense of smell. Although impaired, or injured.
some diagnostic distinctions are easy, the clinician
still has to be careful in making this diagnosis.

DSM-5 CRITERIA FOR CONVERSION DISORDER

• One or more symptoms affect- Ing voluntary

motor or sensory function
• The symptoms are incompatible with recognized
medical disorder
• Symptoms cause significant distress or functional
impairment or warrant medical evaluation
DISSOCIATIVE DISORDERS ways of responding to stress and that severe dissociation
could interfere with memory.

DISSOCIATIVE AMNESIA

Criteria for Dissociative Amnesia

• Inability to remember important personal

information, usually of a traumatic or stressful
nature, that is too extensive to be ordinary
forgetfulness.
• The amnesia is not explained by substances, or
by other medical or psychological conditions.
Specify Dissociative Fugue Sub-type if:
CLINICAL DESCRIPTION • The amnesia is associated with bewildered or
apparently purposeful wandering.
There are three (3) major disorder included in this cluster:
A person diagnosed with dissociative amnesia may be
Dissociative amnesia, depersonalization/derealization
unable to recall important personal information that is
disorder, and dissociative identity disorder. It is presumed
related to trauma (some part of the traumatic experience
to be caused by dissociation which involves the failure of
or, rarely, the entire distressing event) that can't be
consciousness to perform its usual role of integrating our
explained by normal forgetfulness and is not permanently
cognitions, emotions, motivation, and other aspects of
lost.
experience in our awareness.
The amnesia may last for several hours to several years,
Moreover, researchers know less about dissociative
and it may disappear eventually as it began, with complete
disorders compared to other disorders, and there is a
recovery and only a small chance of recurrence.
great deal of controversy about the risk factors for these
disorders, as well as the best treatments. Lastly, during the period of amnesia, the person's behavior
is otherwise unremarkable, except that memory loss may
There were changes made in the previous editions of
cause some disorientation.
DSM. In early versions of the DSM, these disorders and the
anxiety disorders were all classified together as neuroses, DISSOCIATIVE AMNESIA: FUGUE
because anxiety was considered the predominant cause of
The fugue, the subtype of dissociative amnesia, is
these symptoms. But, signs of anxiety are not always
characterized by extensive memory loss and sudden
observable in dissociative disorders and somatic
wandering. Mostly, people with fugue adopt a new
symptom- related disorders. Hence, starting with DSM III,
the diagnostic category of neurosis was abandoned, identity, job, hometown, and personality. Complete
somatic symptom-related disorders and dissociative recovery is possible, although it takes time. After which
disorders separated from each other, and anxiety the person is fully able to remember the details of his life
disorders. and experiences, except for those events that took place
during the fugue.
DISSOCIATION AND MEMORY
The diagnosis is not given on memory loss due to
How memory works under stress? dementia and substance abuse. In dementia, memory fails
slowly over time, is not linked to stress, and is
According to cognitive scientists, extreme stress usually
accompanied by other cognitive deficits.
enhances rather than impairs memory. For example,
children who go through extremely painful medical
procedures have accurate, detailed memories of the
experience. Likewise, people under stress tend to focus on
the central features of the threatening situation and stop
paying attention to peripheral features. Therefore, they
are likely to be unable to connect all aspects of the
stressful situation into a coherent whole. In summary,
extreme trauma enhanced memory of the central features
of the threat.

But these contradict the clinical description of people

with dissociative disorders: stress-related memory loss
happens. Perhaps dissociative disorders involve unusual
DISSOCIATIVE AMNESIA DISSOCIATIVE IDENTITY DISORDER

The pattern of memory deficits in dissociative amnesia Dissociative identity disorder requires that a person has at
highlights an important distinction. Typically, dissociative least two separate personalities or alters that exist
disorders involve deficits in explicit memory but not independently of one another and that emerge at
implicit memory. For example, a woman became amnesic different times.
after being victimized by a practical joke. She had no
However, a person who has recurrent possession states
explicit memory of the event, but she became terrified
that cause distress and otherwise conform to DSM-5
when passing the location of the incident (implicit
criteria may well qualify for the diagnosis.
memory).
The diagnosis also requires that the existence of different
REMEMBER: Amnesia can occur after experiencing severe
alters be chronic; it cannot be a temporary change
distressing situations and not all people experiencing
resulting from the ingestion of a drug.
extreme stress could be diagnosed with dissociative
amnesia. The primary alter may be totally unaware that the other
alters exist and may have no memory of what those other
DEPERSONALIZATION/DEREALIZATION DISORDER
alters do and experience when they are in control. Also, it
Overall, the person’s perception of the self or is typically the one that seeks treatment. The alters are all
surroundings is disconcertingly and disruptively altered aware of lost periods of time.
preceded by stress, yet there is no loss of memory.
DID usually begins in childhood, but it is rarely diagnosed
Specifically, depersonalization is described as the loss of until adulthood. It is more severe and extensive than
sense of self that involves unusual sensory experiences. other dissociative disorders, and recovery may be less
For example, a person may perceive their body parts complete. It is much more common in women than in
change in size, have the impression that he is outside of men.
his body, and feel mechanical or robotic. Meanwhile,
Lastly, many people confuse schizophrenia with DID, as
derealization is characterized by the sensation that the
the former came from the Greek word “schizo” meaning
world has become unreal.
"splitting away from." But, the split or separation of
Criteria for Depersonalization/Derealization personalities in DID is different from the symptoms of
schizophrenia; people with DID do not show the thought
Depersonalization disorder and behavioral disorganization characteristic of
• Experiences of detachment from one’s mental schizophrenia.
processes or body as though one is in a dream.
Derealization Criteria for Dissociative Identity Disorder
• Experiences of unreality of surroundings.
• Symptoms are persistent or recurrent A. Disruption of identity characterized by two or more
• Reality testing remains intact distinct personality states (alters) or an experience of
• Symptoms are not explained by substances, possession, as evidenced by discontinuities in sense of
another dissociative disorder, another self or agency, as reflected in altered cognition,
psychological disorder, or by medical condition. behavior, affect, perceptions, consciousness,
memories, or sensory-motor functioning. This
disruption may be observed by others or reported by
In the DSM 5, derealization was included in the set of the patient.
criteria unlike in DSM-IV-TR which only involved B. Recurrent gaps in recalling events or important
depersonalization. This is based on research that most personal information that are beyond ordinary
people who experience depersonalization also experience forgetting
derealization. Hence, there should be depersonalization, C. Symptoms are not part of a broadly accepted cultural
or religious practice, and are not due to drugs or a
derealization, or both.
medical condition
More so, the DSM-5 diagnostic criteria for D. In children, symptoms are not better explained by an
depersonalization/derealization disorder specify that the imaginary playmate or by fantasy play
symptoms can co-occur with other disorders but should
not be entirely explained by those disorders. Note: The DSM-IV-TR criterion A is less detailed. It
specifies the presence of two or more identities or
personality states (each with its own relatively enduring
pattern of perceiving, relating to, and thinking about
the environment and self). Other changes from DSM-IV-
TR are italicized.
ETIOLOGY OF DISSOCIATIVE IDENTITY DISORDERS REMEMBER! Almost every patient presenting with this
disorder reports to their mental health professional being
1. Posttraumatic Model: Some people are likely to use
horribly, often unspeakably, abused as a child.
dissociation to cope with trauma, which is seen as a key
factor in developing alters after trauma. However, there's ---------------------
no prospective study made yet.
Furthermore, you may have noticed that DID seems
2. Socio-cognitive Model: DID is the result of learning to similar in its etiology to posttraumatic stress disorder
enact social roles. For instance, exposure to media reports (PTSD). Both conditions feature strong emotional
of DID, cultural influences, or suggestions by therapists. reactions to experiencing severe trauma (Butler et al.,
The former implies that DID can be created 1996).
unintentionally within a treatment.
A perspective suggested that DID is an extreme subtype of
"What kinds of evidence have been raised in this PTSD, with a much greater emphasis on the process of
debate?" dissociation than on symptoms of anxiety, although both
are present in each disorder (Butler et al., 1996).
A. D.I.D. symptoms can be role-played? It has been
established that people are capable of roleplaying the TREATMENT OF DISSOCIATIVE IDENTITY DISORDERS
symptoms of DID, particularly the conclusion made in a
There has been an agreement on several principles in the
known 1980s study: 81% of students in the experimental
treatment of dissociative identity disorder:
group adopted a new name, and even the personality test
results of the two personalities differed considerably. 1. Providing an empathic and gentle stance.
2. Aim at helping the client function as one integrated
Therefore, when the situation demands, people can adopt
person by convincing the person that splitting into
a second personality. But this illustrates only that role-
different personalities is no longer necessary to
playing is possible, not that DID results from it.
deal with traumas.
B. Alters share memories, even when they report amnesia 3. Teach the person more effective ways to cope with
stress.
Among the defining features of DID is the inability to recall
information experienced by an alter when a different alter Commonly, DID is treated by psychodynamic-oriented
is present. However, studies suggest that the alters therapists, particularly with the use of hypnosis to recover
actually share memories. memory or gain access to repressed material (Putnam,
1993).
Mostly, research about memories of people with DID
implies that explicit memory is affected, while implicit is Age regression – is an example of a hypnosis technique,
intact. But one study found that people with DID wherein patients access traumatic memories that will
demonstrate more accurate memories than they had allow realizing that childhood threats are no longer
acknowledged. present and that adult life need not be governed by past
trauma (Grinker & Spiegel, 1944). However, according to a
C. The detection of DD differs by clinicians.
multitude of research, it can actually worsen DID
Therapists who are most likely to diagnose DID tend to use symptoms.
hypnosis, to urge clients to try to unbury unremembered
There are still no controlled studies about the treatment
abuse experiences, or to name different alters. However,
result, only clinical observations made by a known
data are still inconclusive.
therapist, Richard Kluft (1994). In general, therapy took
D. Many DID symptoms emerge after treatment starts almost 2 years and 500 hours per patient: the greater the
number of alters, the longer the therapy.
According to the socio-cognitive model, treatment evokes
DID symptoms (Lilienfeld et al., 1999). Meanwhile, the Years after treatment, Kluft (1994) reported 84% of 123
posttraumatic model suggests that most alter began patients had stable integration of identity, and 10% were
existing during childhood and that the therapy just allows functioning better.
the person to become aware of and describe alters.
Comorbidity: anxiety and depression, which can be
The study of Lewis, Yeager, Swica, et al. (1997) supported treated with antidepressants although they may have no
the latter model that some symptoms begin in childhood effect on the DID itself.
for some people diagnosed with DID during adulthood,
although it's still not clear if early symptoms already
included the presence of alters.
 EATING DISORDER switched over to the binge-eating/purging type 8 years
later.
Eating disorders became a distinct category in DSM-IV,
reflecting the increased attention they had received from ONSET: Anorexia Nervosa typically begins in the early to
clinicians and researchers. In DSM-V, eating disorders are middle teenage years, often after an episode of dieting
in a chapter called “Feeding and Eating Disorders,” which and the occurrence of life stress.
also includes childhood disorders, such as pica (eating
PREVALENCE: The literature prevalence of anorexia is less
nonfood substances for extended period) and rumination
than 1 percent, and it is at least 10 times more frequent in
disorders (repeated regurgitation of foods).
women than in men.
Unfortunately, eating disorders are also likely to be
COMORBIDITY: Depression, Obsessive-Compulsive
stigmatized. For instance, participants of the study who
Disorder, Phobias, Panic Disorder, Substance Use
read about that woman with eating disorder viewed her
Disorders, and various personality disorders. For men,
as more responsible, more fragile, and more likely to be
mood disorder, schizophrenia, or substance use disorder.
trying to get attention with her disorder compared to
participants who read about that woman with depression. SUICIDALITY: Quite high for people with anorexia, with as
many as 5 percent completing suicide and 20 percent
CLINICAL DESCRIPTION: ANOREXIA NERVOSA
attempting suicide.
The term anorexia refers to loss of appetite, and nervosa
PHYSICAL CONSEQUENCES: Blood pressure often falls,
indicates that the loss is due to emotional reasons. But the
heart rate slows, kidney and gastrointestinal problems
term is a misnomer as most people with anorexia actually
develop, bone mas decline, the skin dries out, nails
do not lose their appetite or interest in food. It is also
become brittle, hormone levels change, mild anemia may
observable that other people with this disorder become
occur, and loss of hair from the scalp. The drastic decline
preoccupied with food: read cookbooks constantly or
in the levels of potassium and sodium can lead to
prepare gourmet meals to others.
tiredness, weakness, cardiac arrhythmias, and even
1. Restriction of behaviors that promote healthy sudden death. Death most often results from physical
body weight. This is usually taken to mean that complications of the illness – for example, congestive
the person weighs much less than is considered heart failure – and from suicide.
normal (e.g., body mass index (BMI) less than 18.5
PROGNOSIS: Between 50 and 70 percent of people with
for adults) for that person’s age and height.
anorexia eventually recover. However, recovery often
takes 6 or 7 years, and relapses are common before a
Weight loss is typically achieved through dieting,
stable pattern of eating and weight maintenance is
although purging (self-induced vomiting, heavy
achieved.
use of laxatives or diuretics) and excessive
exercise can also be part of the picture. Criteria for Anorexia Nervosa
In DSM-V, amenorrhea (loss of menstrual period) was
• Restriction of food that leads to very low body
removed as one of the criteria for anorexia nervosa, since
weight; body weight is significantly below
there are many reasons why woman can stop having normal.
their menstrual period that do not have anything to do • Intense fear of weight gain
with weight loss. Also, the difference between women • Body image disturbance
diagnosed with anorexia nervosa with amenorrhea and
those without amenorrhea was only a few.
BOLIMIA NERVOSA
DSM-V distinguishes two types of Anorexia Nervosa:
Clinical Description
1. The Restricting Type – weight loss is achieved by
severely limiting food intake. It is characterized by rapid consumption of a large amount
2. The Binge-Eating/Purging Type – the person has of food, followed by compensatory behavior: vomiting,
also regularly engaged in these activities. fasting, or excessive exercise, to prevent weight gain.

A review of the subtype literature for the preparation of • Binge eating an excessive amount of food, that is
DSM-V concluded that the subtypes had limited much more than most people would eat within a
predictive validity even through clinicians found them short period of time. Then, it involves a feeling of
useful. For example, the distinction between subtypes losing control over eating-as if one cannot stop.
may not be all that useful. Nearly two-thirds of women
who initially met the criteria for the restricting subtype
 • Binges typically occur privately that are triggered (Baker et al., 2010; Godart et al., 2000; 2002; Roset et al.,
by stress and negative emotions, and continue 2010; Stice, Burton, & Shaw, 2004).
until the person is uncomfortably full.
SUICIDALITY: Higher than in the general population but
lower compared to anorexia (Franko & Keel, 2006).
• The difference between anorexia and bulimia is
weight loss: anorexia nervosa loses a tremendous PHYSICAL CONSEQUENCES: Frequent purging may lead to
amount of weight, whereas bulimia nervosa does potassium depletion, abused laxatives induce diarrhea,
not. which can also lead to changes in electrolytes and
irregular heartbeat, and swollen salivary glands.
Criteria for Bulimia Nervosa
Recurrent vomiting leads to menstruation problems and
• Recurrent episodes of binge eating damage in the tissue of the throat and stomach and loss
• Recurrent compensatory behaviors to prevent of dental enamel.
weight gain, for example, vomiting
• Body shape and weight are extremely Death is nearly 4% common (Crow et al., 2009).
important for self- evaluation
PROGNOSIS: <75% recover although 10% to 20% remain
fully symptomatic (Keel et al., 1999; 2010; Reas et al.,
What kind of food? 2000; Steinhausen & Weber, 2009).

Food that can be rapidly consumed, like sweets. Also, Early intervention may help with a better diagnosis.
avoiding craved food was associated with a binge episode
CLINICAL DESCRIPTIONS: Binge Eating Disorder
the next day (Waters, Hill, & Waller, 2001).
It includes recurrent binges (once a week for at least 3
BINGE
months), lack of control during the bingeing episode, and
People report that they lose control during a binge, even distress about bingeing. Most people with binge eating
to the point of experiencing something akin to a trancelike disorders are obese. However, not all obese people meet
state, perhaps losing awareness of behavior or feeling that the criteria for their disorder. Since it is important to
it is not really them who are bingeing. Also, they are distinguish, factors must be present: episodes and feelings
usually ashamed of bingeing, which leads them to conceal of loss of control over eating (Yanovski, 2003).
it.
HERITABILITY: Relatives of the person with a binge eating
AFTER THE BINGE IS OVER disorder were more likely to have the same disorder
themselves for about 20% (Hudson et al., 2006).
Emotions such as feelings of discomfort, disgust, and fear
of weight gain led to the second phase: compensatory PREVALENCE: 3.5% for women and 2% for men (Hudson
behavior (purging), to attempt to undo the caloric effects et al., 2006) and equally prevalent among European,
of the binge. African, Asian, and Hispanic Americans (Striegel- Moore &
Franco, 2008).
Types of Purging:
COMORBIDITY: depression and anxiety disorders
1. Induced Vomiting (Wonderlich et al., 2009).
2. Laxative and Diuretic Abuse
3. Fasting and Excessive Exercise PHYSICAL CONSEQUENCE: Many of the physical
consequences ore likely a function of associated obesity,
Previously, in DSM-IV-TR, there were two subtypes such as the increased risk of type 2 diabetes,
available: purging type and non-purging type cardiovascular problems, insomnia, and joint/muscle
(fasting/exercise). But research showed that its validity is problems. Others are independent of co-occurring
weak and it is difficult to distinguish non purging subtype obesity: Sleep problems, anxiety, depression, and irritable
of bulimia and binge-eating disorder. bowel movement (Bulik & Reichborn-Kjennerud, 2003).
ONSET: Late adolescence or early adulthood; binge eating PROGNOSIS: Perhaps because it is a relatively new
often started during an episode of dieting, and may persist diagnosis, fewer studies have assessed the prognosis of
into adulthood and middle age (Keel et al., 2010; Slevec & binge eating disorder. Research so for suggests that
Tiggemann, 2011). between 25 and 82 percent of people recover (Keel &
PREVALENCE: 90% of cases are women, and about 1% to Brown, 2010; Striegel-Moore & Franco, 2000), One
2% of the population have (Hoek & van Hoeken, 2003). retrospective study found that people reported having
their binge eating disorder for an average of 14.4 years,
COMORBIDITY: Depression, personality disorders, anxiety
disorders, substance use disorders, and conduct disorder
which is much longer than people with anorexia or bulimia
report having their disorders (Pope et al., 2006).

Criteria for Binge Eating Disorder

• Recurrent binge eating episodes

• Binge eating episodes include at least three of
the following:
• Eating more quickly than usual eating
until over full.
• Eating large amounts even if not hungry.
• Eating alone due to embarrassment
about large food quantity.
• Feeling bad (e.g., disgusted, guilty, or
depressed) after the binge.
• No compensatory behavior is present.