Onset – the beginning of something
Acute Onset – disorder begin suddenly
CHAPTER 1: ABNORMAL BEHAVIOR IN HISTORICAL CONTEXT
UNDERSTANDING PSYCHOPATHOLOGY
Abnormal Psychology – the study of mental disorders (also called mental illness,
psychological disorders, or psychopathology), what they look like (symptoms), why they occur
(etiology), how they are maintained, and what effect they have on people’s lives.
Abnormal Behavior – a psychological dysfunction within an individual that is associated
with distress or impairment in functioning and a response that is not typically or
culturally expected.
 Psychological Dysfunction
A breakdown in cognitive, emotional, or behavioral functioning. Knowing
where to draw the line between normal and abnormal dysfunction is often
difficult so for these problems, it is considered to be on a continuum or a
dimension rather than to be categories that are either present or absent.
 Distress or Impairment
Causes emotional/physical pain or troubled feelings (being upset; inability
to function effectively. However, for some disorders, suffering and distress
are absent.
 Atypical or not Culturally Expected
Behavior deviates from the average. The greater the deviation, the more
abnormal it is. However, in some cases, the more productive you are in the eyes
of society, the more eccentricities society will tolerate.
What makes behavior abnormal? Remember the 4D = Deviance, Distress, Dysfunction,
and Danger. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-
5), psychological disorder is the behavioral, psychological, or biological dysfunction that are
unexpected in their cultural context and associated with present distress and impairment in
functioning, or increased risk of suffering, death, pain, or impairment.
THE SCIENCE OF PSYCHOPATHOLOGY
Psychopathology is the scientific study of psychological disorders.
Three major categories that make up the study and discussion of psychological disorders:
1. CLINICAL DESCRIPTION represents the unique combination of behaviors, thoughts,
and feelings that make up a specific disorder. One important function of a clinical
description is to specify what makes the disorder different from normal behavior or from
other disorders.
Presenting Problem – indicates why the patient came to the clinic
Prevalence of the Disorder – how many people in the population as a whole have
the disorder.
Incidence of the Disorder – statistics on how many new cases occur during a given
period, such as a year.
Sex Ratio – percentage of males and females that have the disorder.
Course – individual pattern
Chronic Course – they tend to last a long time, sometimes a lifetime
Episodic Course – individual is likely to recover within a few months only
to suffer a recurrence of the disorder at a later time. This pattern may
repeat throughout a person’s life
Time-Limited Course – the disorder will improve without treatment in a
relatively short period with little or no risk of recurrence
Insidious Onset – disorder develop gradually over an extended period of
time
Prognosis – anticipated course of the disorder
“The prognosis is good” – individual can recover
“The prognosis is guarded” – probable outcome doesn’t look good
It is important to know the typical course of a disorder so that we can know what to expect in
the future and how best to deal with the problem. For example, someone is suffering from a
mild disorder with acute onset that we know is time-limited, we might advise the individua
not to bother with expensive treatment because the problem will be over soon enough.
The patient’s age may be an important part of the clinical description. A specific
psychological disorder occurring in childhood may present differently from the same disorder
in adulthood or old age.
2. CAUSATION (ETIOLOGY)
Etiology – study of origins, has to do with why a disorder begins (what causes it) and
includes biological, psychological, and social dimensions.
3. TREATMENT AND OUTCOME
If a new drug or psychosocial treatment is successful in treating a disorder, it may give
us some hints about the nature of the disorder and its causes. For example, if a drug
with specific known effect within the nervous system alleviates a certain psychological
disorder, we know that something in that part of the nervous system might either be
causing the disorder or helping maintain it.
Psychopathology is complex because the effect does not necessarily imply the cause. For
example, we take aspirin for our headache, if we feel better, it does not mean that the
headache is caused by a lack of aspirin (or the ingredients of it).
HISTORICAL CONCEPTIONS OF ABNORMAL BEHAVIOR
1. THE SUPERNATURAL TRADITION/MODEL (14th century – 17th century)
Deviant behavior has been considered a reflection of the battle between good and evil. I
the great Persian Empire, all physical and mental disorders were considered the work of
the devil.
DEMONS AND WITCHES
The bizarre behaviors of individuals afflicted with psychological disorders was seen as
the work of the devil and witches. Individuals possessed by evil spirits were believed to
be responsible for any misfortune experienced by people in the local community.
Treatments include exorcism, shaving the patter of a cross in the hair of the victim’s
head, and securing sufferers to the wall near the front of a church so that they might
benefit from hearing the mass.
STRESS AND MELANCHOLY
Insanity was a natural phenomenon, caused by mental or emotional stress, and it is
curable. Mental depression and anxiety were recognized as illness. Nicholas Oresme,
also suggested that the disease of melancholy (depression) was the source of some
bizarre behavior, rather than demons. Common treatments were rest, sleep, and a
healthy and happy environment. Other treatments include baths, ointments, and
various potions.
TREATMENTS FOR POSSESSIONS
 Possession is seen as involuntary and the possessed individual blameless. Exorcisms
can be relatively painless, however in the Middle Ages, if exorcism fails, some authorities
that steps were necessary to make the body uninhabitable by evil spirits, and many
people were subjected to confinement, beatings, and other forms of torture. One
treatment developed was hanging people over a pit full of poisonous snakes to scare the
evil spirits out of the body. Strangely, it sometimes works and people would come to
their senses and experience relief from the symptoms, only temporarily. This leads to the
creation of many snake pits in many institutions.
MASS HYSTERIA
One fascinating phenomenon is characterized by large-scale outbreaks of bizarre
behavior. In Europe, whole groups of people were simultaneously compelled to run out
in the streets, dance, shout, rave, and jump around in patterns as if they were at a
particularly wild party late at night. This behavior was known by several names,
including Saint Vitus’s Dance and tarantism.
Mass hysteria may simply demonstrate the phenomenon of emotion contagion, in
which the experience of an emotion seems to spread to those around us. People are
suggestible when they are in states of high emotion. Therefore, if a person identifies a
“cause” of the problem, others will probably assume that their own reaction have the
same source. Emotion contagion is thought to spread through contact of victims but
recently, documented cases suggest that it can occur across social networks raising the
possibility that episodes of mass hysteria may increase.
THE MOON AND THE STARS
Paracelsus suggested that the movements of the moon and stars had profound effects of
people’s psychological functioning. He speculated that the gravitational effects of the
moon on bodily fluids might be a possible cause of mental disorders. This influential
theory inspired the word lunatic. This belief is most noticeable today in followers of
astrology.
2. THE BIOLOGICAL TRADITION/MODEL
HIPPOCRATES AND GALEN
Hippocrates and associates wrote Hippocratic Corpus which suggested that
psychological disorders might also be caused by brain pathology or head trauma and
could be influences by heredity. He considered the brain to be the seat of wisdom,
consciousness, intelligence, and emotion. Therefore, disorders involving these functions
would logically be located in the brain. He also recognized the importance of
psychological and interpersonal contributions, such as the sometimes-negative effects of
family stress, on some occasions, he removed patients from their families.
One of the most influential of the Hippocratic-Galenic approach is the humoral theory
of disorders where, normal brain functioning was related to four bodily fluids or
humors; blood, black bile, yellow bile, and phlegm. Physicians believed that disorders
resulted from too much or too little of one of the humors. Treatments are rest, good
nutrition, exercise, bloodletting/bleeding (through leeches), and induced vomiting
(Robert Burton recommended eating tobacco and half-boiled cabbage to induce
vomiting).
Hippocrates coined the word hysteria to describe a concept he learned from the
Egyptians. Egyptians assumed that somatic symptom disorders were restricted to
women which is caused by the empty uterus wandering to various parts of the body in
search of conception. Prescribed cure might be marriage or fumigation of the vagina to
lure the uterus back to its natural location.
In ancient China, unexplained mental disorders were caused by blockages of wind or the
presence of cold dark wind (yin) as opposed to warm, life-sustaining wind (yang).
Treatment includes restoring proper flow of wind through various methods, including
acupuncture.
19TH CENTURY
The biological tradition was reinvigorated in the 19 th century because of two factors: the
discovery of the nature and cause of syphilis and strong support from the well-respected
American psychiatrist John P. Grey. Grey’s position was that the cause of insanity were
always physical, therefore mentally ill patients should be treated as physically ill. Grey
even invented the rotary fan to ventilate his large hospital. Under his leadership,
hospitals’ conditions greatly improved however, they became so large and impersonal
that individual attention was not possible.
THE DEVELOPMENT OF BIOLOGICAL TREATMENTS
In 1930s, the physical intervention of electric shock and brain surgery were often used.
Their effects, and the effects of new drugs, were discovered quite by accident. With the
discovery of Rauwolfia serpentine (reserpine) and neuroleptics (major tranquilizers), for
the first time hallucinatory and delusional thought processes could be diminished in
some patients; these drugs also controlled agitation and aggressiveness.
Benzodiazepines (minor tranquilizers) seemed to reduce anxiety. However, side effects
were later discovered which halt the prescriptions of these drugs.
3. PSYCHOLOGICAL TRADITION/MODEL
Plato thought that the two cause of maladaptive behavior were the social and cultural
influences in one’s life and the learning that took place in that environment. This was
very much a precursor to modern psychosocial treatment. Aristotle emphasized the
influence of social environment and early learning on later psychopathology. They also
advocated humane and responsible care for individuals with psychological disturbances.
MORAL THERAPY
During the first half of the 19 th century, moral therapy became influential. It includes
treating institutionalized patients as normally as possible in a setting that encouraged
and reinforced normal social interactions, thus providing them with many opportunities
for appropriate social and interpersonal contact. Moral therapy as a system originated
from Philippe Pinel and Jean-Baptiste Pussin. Asylums has appeared in the 16 th century,
but they were more like prisons than hospitals. It was the rise of moral therapy that
made asylums habitable and even therapeutic.
ASYLUM REFORM AND THE DECLINE OF MORAL THERAPY
Unfortunately, after the mid-19th century, humane treatment declined because of a
convergence of factors. After the Civil War, waves of immigrants arrived yielding their
own population of mentally ill. A final blow to the practice of moral therapy was the
decision that mental illness was caused by brain pathology and therefore, was incurable.
Psychological tradition emerged in the 20 th century with psychoanalysis as the first
major approach, seconded by behaviorism.
THE INTEGRATIONIST APPROACH TO UDERSTANDING MENTAL HEALTH
Many mental health theories today strive to integrate biological, psychological and social
factors in understanding mental health issues. We now realize that no contribution to
psychological disorders ever occur in isolation. Our behavior, both normal and abnormal, is a
product of a continual interaction of psychological, biological, and social influences.
 Individuals inherit tendencies to express certain behaviors, which may be
CHAPTER 2: AN INTEGRATIVE APPROACH TO PSYCHOPATHOLOGY activated under conditions of stress. Each inherited tendency is a
diathesis/vulnerability, a condition that makes someone susceptible to
No influence operates in isolation. Each dimension – biological or psychological – is strongly developing a disorder. When the right kind of life events, such as a certain type
influenced by the others and by development, and they weave together in various complex of stressor come along, the disorder develops.
and intricate ways to create a psychological disorder.
Diathesis is genetically based and the stress is environmental but that they
One-dimensional model – attempts to trace the origins of behavior to a single cause
must interact to produce a disorder. The smaller the vulnerability, the greater
Multidimensional model – considers the interaction of all relevant dimensions
the life stressor required to produce the disorder; the greater the vulnerability,
less life stress is required.
GENETIC CONTRIBUTION TO PSYCHOPATHOLOGY
THE NATURE OF GENES 2. THE RECIPROCAL GENE-ENVIRONMENT MODEL (GENE-ENVIRONMENT
Most of our behavior, our personality, and even our intelligence are probably polygenic –
influenced by many genes. Although all cells contain our entire genetic structure, only a CORRELATIONS)
small proportion of the genes in any one cell are “turned on” or expressed. What is interesting
is that environmental factors, in the form of social and cultural influences, can determine
whether genes are turned on.

About half of our enduring personality traits and cognitive abilities can be attributed to
genetic influence. A study about twins confirmed that during adulthood, genetic factors
determine the stability in cognitive abilities, whereas environmental factors were responsible
for any changes.

Adverse life events such as a chaotic childhood can overwhelm the influence of genes. For
psychological disorders, evidence indicates that genetic factors make some contributions to
all disorder but account for less than half of contributions. Example, one of the pair of
identical twins has schizophrenia, there is a less-than 50% likelihood that the other twin will Genetic endowment may increase the probability that an individual will
also have schizophrenia. experience stressful life events. These people might have a genetically
determined tendency to create the very environmental risk factors that trigger
Specific genes or small group of genes may be associated with certain psychological a genetic vulnerability.
disorders, but that contributions come from many genes, each having a relatively small
effect. Genetic contributions cannot be studies in the absence of interaction with events in
Although environment cannot change our DNA, it can change the genetic
the environment that trigger genetic vulnerability or ‘turn on’ genes.
expression. Genes are turned on/off by cellular materials that is located just
THE INTERACTION OF GENES AND THE ENVIRONMENT outside of the genome, and that stress, and other factors can affect this
Eric Kandel suggested that the very genetic structure of cells may change as a result of epigenome, which is then immediately passed down to the next generations.
learning if genes that were inactive or dormant interact with the environment in such a way
that they become active. The environment may occasionally turn on certain genes. NEUROSCIENCE AND ITS CONTRIBUTIONS TO PSYCHOPATHOLOGY
The brain and its function are plastic, subjected to continual change in response to the
environment, even at the level of genetic structure. Two models have received the most
attention:

1. THE DIATHESIS-STRESS MODEL

THE CENTRAL NERVOUS SYSTEM  Endorphin – euphoria; released during exercise, excitement and sex. Producing
The central nervous system processes all information received from our sense organs and a sense of well-being and pain reduction.
reacts as necessary. It sorts out what is relevant from what isn’t, checks the memory banks BEHAVIORAL AND COGNITIVE SCIENCE
to determine why the information is relevant, and implements the right reaction. The spinal  Learned helplessness – people become depressed if they decide or think they can do
cord is part of the CNS, but its primary function is to facilitate the sending of messages to little about the stress in their lives, even if it seems to others that there is something
and from the brain. The brain uses an average of 140 billion nerve cells, called neurons, to they could do.
control our thoughts and action. Neurons transmit information throughout the nervous  Learned optimism – if people faced with considerable stress and difficulty in their lives
system. nevertheless display an optimistic, upbeat attitude, they are likely to functions better
psychologically and physically.
THE PERIPHERAL NERVOUS SYSTEM
 Observational learning – organisms do not have to experience certain events in their
The PNS coordinates with the brain stem to make sure the body is working properly. Two
environment to learn effectively, they can learn just as much by observing what happens
major components are:
to someone else in a given situation.
Somatic Nervous System
 Prepared learning – we have become highly prepared for learning about certain types of
Controls the muscles, so damage in this area might make it difficult for us to engage in any
objects or situations over the course of evolution because this knowledge contributes to
voluntary movement, including talking.
the survival of the species.
Autonomic Nervous System
Primary duties are to regulate the cardiovascular system, endocrine system, and to perform EMOTIONS
various other functions, including aiding digestion and regulating body temperature. Emotion is linked to an action tendency to behave in a certain way, elicited by an external
Includes the sympathetic and parasympathetic nervous system. event and a feeling state and accompanied by a characteristic physiological response. One
Endocrine system – produces its own chemical messenger (hormones), and purpose of a feeling state is to motivate us to carry out a behavior. Emotions are usually
releases it directly into the bloodstream. short-lived, temporary states lasting from several minutes to several hours, occurring in
Adrenal glands – produce epinephrine (adrenaline) in response to stress. The response to an external event.
cortical part of this gland produces the stress hormone cortisol. This system is
called the hypothalamic-pituitary-adrenocortical axis (HPA axis). Dysregulation Mood is a more persistent period of affect or emotionality. Affect often refers to the valence
of the HPA is linked to depression. (positive or negative/ pleasant or unpleasant) dimension of an emotion.
Thyroid gland – produces thyroxine which facilitates energy metabolism and
growth.
Pituitary gland – master gland; produces a variety of regulatory hormones Basic emotions of fear,
Gonadal gland – produces sex hormones such as estrogen and testosterone. anger, sadness or distress,
and excitement may
Sympathetic Nervous System is primarily responsible for mobilizing the body contribute to many
during times of stress or danger by rapidly activating the organs and glands under psychological disorders and
its control. This system mediates the flight or fight response. may even define them.
Parasympathetic Nervous System balance the sympathetic system. It normalizes Emotions and mood also
our arousal and facilitates the storage of energy by helping the digestive process. affect our cognitive
processes; if your mood is
KEY NEUROTRANSMITTERS positive, then your
association, interpretations,
 Adrenaline/Epinephrine – fight or flight; produced in stressful situations, and impressions also tend to
increases heart rate and blood flow, leading to physical boost and heightened be positive.
awareness.
 Noradrenaline/Norepinephrine – concentration; affects attention and
responding actions in the brain. Contract blood vessels, increasing blood flow.
 Dopamine – pleasure; feelings of pleasure, also addiction, movement and
motivation. People repeat behaviors that lead to dopamine release.
 Serotonin – mood; contributes to well-being and happiness. Helps sleep cycle
and digestive system regulation. Affected by exercise.
 Gamma-aminobutyric acid (GABA) – calming; calms firing nerves in the CNS.
High levels improve focus, low levels cause anxiety. Also contributes to motor
control and vision.
 Acetylcholine – learning; involved in thought, learning, and memory. Activates
muscle action in the body. Also associated with attention and awakening.
 Glutamate – memory; most common neurotransmitter. Involved in learning
and memory, regulates development and creation of nerve contacts.
CULTURAL, SOCIAL, AND INTERPERSONAL FACTORS CHAPTER 3: CLINICAL ASSESSMENT AND DIAGNOSIS
 Fear and phobias are universal, occurring across all cultures. But what we fear is ASSESSING PSYCHOLOGICAL DISORDERS
strongly influenced by our social environment. The likelihood of someone having a The process of clinical assessment and diagnosis are central to the study of psychopathology
particular phobia is powerfully influenced by gender. These substantial differences have and to the treatment of psychological disorders.
to do with cultural expectations of men and women, or our gender roles. Clinical Assessment – systematic evaluation and measurement of psychological, biological,
 The greater the number and frequency of social relationships and contacts, the longer and social factors of an individual presenting with a possible psychological disorder.
you are likely to live. The lower you score on a social index that measures the richness of Diagnosis – the process of determining whether the particular problem afflicting the
your social life, the shorter your life expectancy. individual meets all criteria for a psychological disorder, as set forth in the fifth edition of the
 Studies show that social relationships seem to protect individuals against many physical Diagnostic and Statistical Manual of Mental Disorder (DSM-5)
and psychological disorders. The risk of depression for people who live alone is 80%
higher than people who live with others. Social isolation increases the risk of death. KEY CONCEPTS IN ASSESSMENT
 It is not just the absolute number of social contacts that is important. It is the actual The process of clinical assessment in
perception of loneliness. psychopathology has been likened to a
 Some people think interpersonal relationships give meaning to life and tat people who funnel. Clinicians begins by collecting a
have something to live for can overcome physical deficiencies and even delay death. lot of information across a broad range
 Many major psychological disorders, such as schizophrenia and major depressive of the individual’s functioning to
disorder, seem to occur in all cultures, but they may look different from one culture to determine where the source of the
another because individual symptoms are strongly influenced by social and problem may lie. The clinician then
interpersonal context. narrows the focus by ruling out
 In lifespan devel0pemnt, there is what we call the principle of equifinality, in which we problems in some areas and
consider a number of paths to a given outcome. Different paths can result from the concentrating on areas that seem most
interaction of psychological and biological factors during various stages of development. relevant.

One of the way psychologists improve

their reliability is by carefully designing
their assessment devices and then
conducting research on them to ensure
that two or more raters will get the
same answer (interrater reliability).
They also determine whether these
assessment techniques are stable
across time through test-retest
reliability.

CATEGORIES OF ASSESSMENT TOOLS

THE CLINICAL INTERVIEW
Clinical interview is the core of most clinical work. The interviewer gathers information about
the individual on all aspects of his life. To organize the information obtained during an
interview, many clinicians use a mental status exam. May be structured or unstructured.

THE MENTAL STATUS EXAM (Structured)

Systematic observation of an individual’s behavior. Clinicians organize their observations of
other people in a way that gives them sufficient information to determine whether a
psychological disorder might be present. The exam covers five categories:
1. Appearance and behavior – overt behavior, attire, appearance, posture,
expressions
2. Thought processes – rate of speech, continuity of speech, content of speech
3. Mood and affect – predominant feeling state of the individual (mood); feeling state
accompanying what individual says, may be appropriate or inappropriate (affect)
4. Intellectual functioning – type of vocabulary, use of abstraction and metaphors
5. Sensorium – awareness of surroundings in terms of person (self and clinician),
time, and place – “oriented times three”
Patients usually have an idea of their major concerns in a general sense; but occasionally,
the problem reported may not be, after assessment, be the major issue in the eye of the
clinician. It is important when conducting the interview that the clinician elicits the patient’s
trust and empathy.
SEMISTRUCTURED CLINICAL INTERVIEWS
Most clinicians after training, develops their own methods of collecting necessary information
from patients. Semistructured interviews are made up of questions that have been carefully
phrased and tested to elicit useful information in a consistent manner so that clinicians can
be sure they have inquired about the most important aspects of particular disorders.
PHYSICAL EXAMINATION
Many problems presenting as disorders of behavior, cognition, or mood may, on careful
physical examination, have a clear relationship to a temporary state. This toxic state could be
caused by bad food, wrong amount/type of medication, or onset of a medical problem. If a
current medical condition or substance abuse exists, the clinician must ascertain whether it
is merely coexisting or is causal, usually by looking at the onset of the problem.
BEHAVIORAL ASSESSMENT
By using direct observations to formally assess an individual’s thoughts, feelings, and
behavior in specific situations or context, behavioral assessment may be more appropriate
than an interview in terms of assessing individuals who are not old enough or skilled enough
to report their problems and experience.
Clinicians can also go to the person’s home or workplace or even into the local community to
observe the person and the reported problem directly. Others set up a role-paly stimulations
in a clinical setting to see how people might behave in similar situations in their daily lives.
In behavior assessment, target behaviors are identified and observed with the goal of
determining the factors that seem to influence them. These types of observations are useful
when developing screenings and treatments.
THE ABCs OF OBSERVATION
Clinician’s attention is usually directed to the immediate behavior, its antecedents (what
happened before the behavior), and its consequences (what happened afterward). Once the
target behavior is selected and defined, and observer writes down each time it occurs, along
with its antecedents and consequences. The goal of is to see whether there are any obvious
patterns of behavior and then to design a treatment based on these patterns.
SELF-MONITORING
People can observe their own behavior to find patterns, a technique known as self-
monitoring/self-observation. This observation can tell them exactly how big their problem
is and what situation leads them to these problems. The goal is to help client monitor their
behavior more conveniently.
A more formal and structured way to observe behavior is through checklists and behavior
rating scales, which are used as assessment tools before treatment and then periodically
during treatment to assess changes in person’s behavior.
Reactivity can distort any observational data. Any time you observe how people behave; the
mere fact of your presence may cause them to change their behavior. Clinicians sometimes
depend on the reactivity of self-monitoring to increase the effectiveness of their treatments.
Behavioral Assessment have its own advantages like reactivity, observer may experience
overload (fail to record all important details), observer drift (decline in accuracy), and
observer bias. So, it is not always valid and reliable.
PSYCHOLOGICAL TESTING
Tests used to assess psychological disorders must meet the strict standards and must be
reliable. Psychological tests include specific tools to determine cognitive, emotional, or
behavioral responses that might be associated with a specific disorder and more general tools
that assess long-standing personality feature.
PROJECTIVE TESTING
This includes a variety of methods in which ambiguous stimuli are presented to people who
are asked to describe what they see. The theory is that people project their own personality
and unconscious fears onto other people and things (the ambiguous stimuli), and without
realizing it, reveal their unconscious thought to the therapist.
A. Rorschach Inkblot Test (Hermann Rorschach)
Includes 10 inkblot pictures that serve as the ambiguous stimuli. Done by
presenting one inkblot card one at a time and asking respondents what they see,
what the inkblots seem to be, or what it reminds them of. It looks into themes,
images and response style.
B. Thematic Apperception Test (Christiana Morgan and Henry Murray)
Consists of a series of 31 cards – 30 with pictures on them and 1 blank card – the
instructor asks the person to tell a dramatic story about the picture.
C. Sentence Completion Test
This test asks people to complete a series of unfinished sentences
D. Drawings
Evaluations are based on the details and shape of the drawing, solidity of pencil
line, location of the drawing on the paper, size of the figure, use of background, and
comments made by the client during the task.
PERSONALITY INVENTORIES
Personality Inventories – are self-report questionnaires that assess personal traits. What is
necessary from these types of tests is not whether the questions necessarily make sense on
the surface but, rather, what the answers to these questions predict.
The most widely used personality inventory is the Minnesota Multiphasic Personality
Inventory (MMPI). Individual responses on the MMPI are not examined; instead, the pattern
of responses is reviewed to see whether it resembles pattern these groups of people who have
specific disorders.
INTELLIGENCE TESTING
Intelligence tests were developed to predict who would do well in school. Alfred Binet and
Theodore Simon were commissioned by the French government to develop a test that would
identify slow learners who would benefit from remedial help.
The test provides a score known as an intelligence quotient (IQ). A person’s score is
compared only with scores of others of the same age. The IQ score, then, is an estimate of
how much a child’s performance in school will deviate from the average performance of
others of the same age (deviation IQ). IQ tests tend to be reliable, and to the extent that they
predict academic success, they are valid assessment tools.
NEUROPSYCHOLOGICAL TESTING
Neuropsychological tests detect brain impairment by measuring a person’s cognitive,
perceptual, and motor performance (e.g., Bender Visual-Motor Gestalt Test). This method of
testing assesses brain dysfunction by observing the effects of the dysfunction on the person’s
ability to perform certain tasks. Although you do not see the damage, you can see its effects.
This type of studies raises the issues of false positives and false negatives.
NEUROLOGICAL TESTS
Directly measures brain structure or activity.
NEUROIMAGING; PICTURES OF THE BRAIN
A technique that has the ability to look inside the nervous system and take increasingly
accurate pictures of the structure and function of the brain.
 IMAGES OF BRIAN STRUCTURE:
1. Computerized Axial Tomography (CAT) Scans which are useful in locating
brain tumors, injuries, and other structural and anatomical abnormalities.
2. Magnetic Resonance Imaging (MRI) where head is placed in a high-strength
magnetic field through which radio frequency signals are transmitted. Where
there are lesions or damages, the signal is lighter or darker.
 IMAGES OF BRAAIN FUNCTIONING
1. Positron Emission Tomography (PET) Scan in which subjects are injected with
a tracer substance that interacts with blood, oxygen, or glucose. Through this,
we can learn what parts of the brain are working and what parts are not.
2. Single Photon Emission Computed Tomography (SPECT) which works like PET,
although a different tracer substance is used; this procedure is somewhat less
accurate.
3. Functional MRI (fMRI) allows researcher to see the immediate response of the
brain to a brief event.
PSYCHOPHYSIOLOGICAL TESTS
Measures physiological responses as possible indicators of psychological problems. Examples
are polygraph or lie detector and EEG
DIAGNOSING PSYCHOLOGICAL DISORDERS
If we want to determine what is unique about an individual, we use idiographic strategy
that let us tailor our treatment to the person. Nomothetic strategy on the other hand let us
determine a general class of problems to which the presenting problem belongs. When we
identify a specific psychological disorder in the clinical setting, we are making a diagnosis.
Classification refers to any effort to construct groups/categories and to assign objects/people
to these categories on the basis of their shared attributes or relations (a nomothetic strategy).
Most widely used classification system is the DSM and International Classification of
Disease. A clinician refers t o the DSM-5 to identify a specific psychological disorder in the
process of making a diagnosis.
CLASSIFICATION ISSUES
APPROACHES FOR ORGANIZING AND CLASIFYING BEHAVIORAL DISORDERS
The classical (pure) categorical approach to classification originates in the work of Emil
Kraepelin and the biological tradition in the study of psychopathology. Here we assume that
every diagnosis has a clear underlying pathophysiological cause and that each disorder is
unique. The mental health field has not adopted this model because of its inappropriateness
to the complexities of psychological disorders.
Dimensional approach notes the variety of cognitions, moods, and behaviors with which the
patient presents and quantify them on a scale. It is relatively unsatisfactory and most
theorists have not been able to agree on how many dimensions are required.
Prototypical approach identifies certain essential characteristics of an entity so that it can be
classified, but it also allows certain nonessential variations that do not necessarily change
the classification.
RELIABILITY
Unreliable classification systems are subject to bias by clinicians making diagnosis. One of
the most unreliable categories in current classification is the area of personality disorders –
chronic, trait-like sets of inappropriate behaviors and emotional reactions that characterize a
person’s way of interacting with the world.
VALIDITY
A system of nosology must be valid (construct validity, predictive validity, criterion validity,
content validity).
DIAGNOSIS AND THE DSMs
Early efforts to classify psychopathology arose out of the biological traditions from the work
of Emilin Kraepelin. He identified dementia praecox (schizophrenia), manic depressive
psychosis (bipolar disorder), and theorize that psychological disorders are basically biological
disturbances.
It was not until 1948 that WHO added a section classifying mental disorders to the ICD.
Along with it is the creation of DSM-I (1952) and DSM-II. These systems lacked precision,
often relying heavily on unproven theories of etiology not widely accepted by all mental health
professionals.
DSM-III (1980) attempted to take a theoretical approach to diagnosis and the specificity and
detail with which the criteria for identifying a disorder were listed made it possible to study
their reliability and validity. Precise descriptive format and its neutrality with regards to
presuming a cause for diagnosis made it popular during those times.
In DSM-IV, there was a distinction between organically-based disorders and psychologically-
based disorders. Currently, DSM-V (2013) is the recent followed by DSM-V-TR (2022).
Criticism in DSM-V includes the problem of comorbidity, where individuals are often
diagnosed with more than one psychological disorder at the same time.
It is important to emphasize that impairment is a crucial determination in making any
diagnosis. It is essential that the various behaviors and cognitions comprising the diagnosis
interfere with the functioning in some substantial manner. Individuals who have all the
symptoms but do not cross the threshold of impairment could not be diagnosed with a
disorder.

CHAPTER 5: ANXIETY, TRAUMA- AND STRESSOR- RELATED, AND
OBSESSIVE-COMPULSIVE AND RELATED DISORDERS
THE COMPLEXITY OF ANXIETY DISORDERS
ANXIETY, FEAR, AND PANIC: SOME DEFINITIONS
Anxiety – is a negative mood state characterized by bodily symptoms of physical tensions
and by apprehension about the future.
 Anxiety is good in moderate amounts; we perform better when we are a little
anxious. Social, physical, and intellectual performances are driven and enhanced by
anxiety.
 Howard Liddell called anxiety as “the shadow of intelligence”, the human ability
to plan in some details for the future was connected to that gnawing feeling that
things could go wrong and we had better be prepared for them.
 Future-oriented mood state, characterized by apprehension because we cannot
predict or control upcoming events.
 Negative affect and somatic symptoms of tension
Fear – is an immediate alarm reaction to danger.
 Help protects us by activating the Autonomic Nervous System; this emergency
reaction is often called the flight or fight response.
 An immediate emotional reaction to current danger characterized by strong
escapist action tendencies and, often, a surge in the sympathetic branch of the ANS.
 Negative Affect
Panic Attack – abrupt experience of intense fear or acute discomfort, accompanied by
physical symptoms that usually include heart palpitations, chest pain, shortness of breath,
and possibly dizziness.
 There are two types of panic attacks described in DSM-5:
1. Expected (Cued) Panick Attack – If you know you are afraid of something,
you might have a panic attack in these situations but not anywhere else.
More common in specific phobias or social anxiety disorder.
2. Unexpected (Uncued) Panic Attacks – you don’t have a clue when or where
the next attack will occur. Unexpected attacks are important in panic
disorders.
Table 5.1 Diagnostic Criteria for Panic Attack
An abrupt surge of intense fear or intense discomfort that reaches a peak within a minute,
and during which time four (or more) of the following symptoms occur:
1. Palpitations, pounding heart, or accelerated heart rate
2. Sweating
3. Trembling or shaking
4. Sensations of Shortness of breath or smothering
5. Feeling of choking
6. Chest pain or discomfort
7. Nausea or abdominal distress
8. Feeling dizzy, unsteady, lightheaded, or faint
9. Chills or heat sensations
10. Paresthesias (numbness or tingling sensations)
11. Derealization (feelings of unreality) or depersonalization (being detached from oneself)
12. Fear of losing control or going crazy
13. Fear of dying
CAUSES OF ANXIETY AND RELATED DISORDERS
BIOLOGICAL CONTRIBUTIONS
We inherit a tendency to be tense, uptight, and anxious. The tendency to panic also
seems to run in families and probably has a genetic component. However no single gene
causes it but instead, contributions from collections of genes make us vulnerable when the
right psychological and social factors are in place. Genetic vulnerability does not cause
anxiety and/or panic directly, stress or other factors in the environment can ‘turn on”
these genes.
Anxiety is also associated with specific brain circuits and neurotransmitter systems:
 Depleted level of GABA (part of GABA-benzodiazepine system) is associated
with increased anxiety
 Noradrenergic system has also been implicated in anxiety
 Serotonergic neurotransmitter system is also involved
 CRF (corticotropin-releasing factor) activates the hypothalamic-pituitary-
adrenocortical (HPA) axis which has a wide-ranging effect on areas of the brain
implicated in anxiety, including the emotional brain (limbic system),
particularly the amygdala and hippocampus. CRF is also directly related to the
three systems mentioned earlier
The area of the brain most often associated with anxiety is the limbic system. Brains
stem monitors and senses changes in bodily function and relays it to higher cortical
processes through the limbic system. Jeffrey Gray identified a brain circuit in the limbic
system of animals that seems heavily involved in anxiety, which is called the behavior
inhibition system (BIS).
 BIS is activated by signals from the brain stem of unexpected events, such as major
changes in body functioning that might signal danger. Danger signals in response to
something we see that might be threatening descend from the cortex to the septal-
hippocampal system
 BIS receives big boost from the amygdala
 When activated by signal from brain stem, our tendency is to freeze, experience
anxiety, and apprehensively evaluate the situation to confirm that danger is present
 BIS circuit is distinct from the circuit involved in panic.
Gray and McNaughton identified the fight/flight system (FFS):
 Originates in the brain stem and travels through several midbrain structures
including the amygdala, the ventromedial nucleus of the hypothalamus, and the
central gray matter
 Activated partly by deficiencies in serotonin
 In people with anxiety disorders, the limbic system, including the amygdala, is
overly responsive to stimulation or new information; at the same time, controlling
functions of the cortex that would down-regulate the hyperexcitable amygdala are
deficient
PSYCHOLOGICAL CONTRIBUTIONS
In childhood, we may acquire an awareness that events are not always in our control. A
general “sense of uncontrollability” may develop early as a functioning of upbringing and
other disruptive or traumatic environmental factors.

The actions of parents in early childhood seem to do a lot to foster this sense of control
or uncontrollability. A sense of control (or lack of it) that develops from early experiences is
the psychological factors that makes us more or less vulnerable to anxiety in later life.

Another feature among patients with panic is the general tendency to respond fearfully to
anxiety symptoms (anxiety sensitivity), an important trait that determines who will and
who will not experience problems with anxiety under certain stressful conditions.
AN INTEGRATED MODEL
Putting the factors together in an integrated way, we have described a theory of development
on anxiety called the triple vulnerability theory
1. Generalized Biological Vulnerability – a tendency to be uptight or high-strung might
be inherited
2. Generalized Psychological Vulnerability – you might grow believing the world is
dangerous and out of control and you might not be able to cope when things go
wrong, based on your experiences
3. Specific Psychological vulnerability – you learn from early experiences, such as
being taught by your parents, that some situations or objects are fraught with
danger (even if they really aren’t)
COMORBIDITY
Comorbidity – the co-occurrence of two or more disorders in a single individual
 There is a high rate of comorbidity among anxiety and related disorders (and
depression), which emphasize how all these disorders share the common features of
anxiety and panic
 They also share the same vulnerabilities to develop anxiety and panic
 They differ only in what triggers the anxiety and the patterning of panic attacks
 Presence of any anxiety disorder was uniquely associated with thyroid disease,
respiratory disease, gastrointestinal disease, arthritis, migraine headaches, and
allergic conditions
 Panic attacks often co-occur with certain medical conditions, particularly cardio,
respiratory, gastrointestinal, and vestibular (inner ear) disorders
20% of patients with panic disorders had attempted suicide. Having any anxiety disorders
increases the chances of having thoughts about suicide (suicide ideation) or making suicidal
attempts, but the relationship is strongest with panic disorder and PTSD.
ANXIETY DISORDERS
(1) GENERALIZED ANXIETY DISORDER (GAD)
 Worrying indiscriminately about everything
 Worrying is unproductive
 You can’t seem to decide what to do with an upcoming problem or situation
 You can’t stop worrying, even if you know it is doing you no good and probably
making everyone else around you miserable
CLINICAL DESCRIPTIONS
Table 5.2 Diagnostic Criteria for Generalized Anxiety Disorder
A. Excessive anxiety and worry (apprehensive expectations), occurring more days than
not for at least 6 months about a number of events or activities (such as work or
school performance)
B. The individual finds it difficult to control the worry
C. The anxiety and worry are associated with at least three (or more) of the following six
symptoms (with at least some symptoms present for more days than not for the past
6 months) [Note: Only one item is required in children];
1. Restlessness or feeling keyed up or on edge
2. Being easily fatigued
3. Difficulty concentrating or mind going blank
4. Irritability
5. Muscle tension
6. Sleep disturbance (difficulty falling or staying asleep or restless, unsatisfying
sleep)
D. The anxiety, worry or physical symptoms cause clinically significant distress or
impairment in social, occupational, or other important areas of functioning
E. The disturbance is not due to the direct physiological effects of a substance (e.g., a
drug of abuse, medication) or a general medical condition (e.g., hyperthyroidism)
F. The disturbance is not better explained by another mental disorder (e.g., anxiety or
worry about having panic attacks in panic disorder, negative evaluation in social
anxiety disorder)
People with GAD mostly worry about minor, everyday life events, a characteristic that
distinguishes GAD from other anxiety disorders.
STATISTICS
 GAD is one of the most common anxiety disorders.
 About twice as many individuals with GAD are female than male, but this sex ratio may
be specific to developed countries.
 Some people with GAD report onset in early adulthood, usually in response to life
stressors. The median age of onset is 31.
 Once it develops, GAD is chronic. After the beginning of an episode of GAD, there was
only a 58% chance of recovering. 45% of those individuals who recovered were more
likely to relapse later. GAD follows a chronic course, characterized by waxing and
waning of symptoms.
 GAD is prevalent among older adults, most common in groups over 45 years old and
least common in younger group, ages 15-24.
CAUSES
Difference in GAD from other anxiety disorders:
 Physiological responsivity. Individuals with GAD shows less responsiveness on
physiological measures about stressors, such as heart rate, blood pressure, skin
conductance, and respiration rate.
 Low cardiac vagal tone leading to autonomic inflexibility, because the heart is less
responsive to certain tasks. Therefore, people with GAD are called autonomic
restrictors.
 People with GAD are chronically tense
 Highly sensitive to threat in general. They allocate their attention more readily to sources
of threat
 Although the peripheral autonomic arousal of people with GAD is restricted, they
showed intense cognitive processing in the frontal lobes as indicated by EEG activities,
particularly in the left hemisphere.
 Individuals with GAD avoid images associated with the threat. They avoid processing
the images and negative affect associated with anxiety and they avoid much of the
unpleasantness and pain associated with the negative affect and imagery. Therefore,
they are never able to work through their problems and arrive at solutions and they
become chronic worriers, with accompanying autonomic inflexibility and quite severe
muscle tension.
 The intense worrying prevents the person from facing the feared or threatening situation,
so adaptation never occurs.
TREATMENTS
Both drugs and psychological treatments are effective
Drug Treatments (effective only on short periods):
 Benzodiazepines are most often prescribed for generalized anxiety but it only
provides short relief and has negative side effects. Can only be prescribed for
temporary crisis and use is for no more than two weeks.
 Antidepressants such as paroxetine and venlafaxine, which is a better choice
than benzodiazepines
Psychological Treatments (more effective in the long term):
 Cognitive-Behavioral Treatment (CBT) for GAD in which patients evoke the
worry process during therapy sessions and confront threatening images and
thoughts head-on.
 Meditational and mindfulness-based approaches help teach the patient to be
more tolerant of the feelings.
(2) PANIC DISORDER AND AGORAPHOBIA
Panic Disorder – individuals experience severe, unexpected panic attacks, they may think
they’re dying or otherwise losing control. This disorder is sometimes accompanied by
agoraphobia.
Agoraphobia – is the fear and avoidance of situations in which a person feels unsafe or
unable to escape to get home or to a hospital in the event of a developing panic, panic-like
symptoms, or other physical symptoms, such as loss of bladder control. People develop
agoraphobia because they never know when these symptoms might occur.
The four major specific phobia categories are: Natural Environment, Animals,
Mutilation/Medical Treatment, Situations
CLINICAL DESCRIPTIONS
Panic Disorder: A person must experience an unexpected panic attack and develop
substantial anxiety over the possibility of having another attack or about the implications of
the attack or its consequences. The person must think that each attack is a sign of
impending death or incapacitation. They may avoid going to certain places or neglect their
duties around the house for fear an attack might occur if they are too active.
Agoraphobia: most agoraphobic avoidance behavior is simply a complication of severe,
unexpected panic attacks. Anxiety is diminished for individuals with agoraphobia if they
think a location or person is safe, even if there is nothing effective the person could do if
something bad did happen to the patient. For these reasons, agoraphobics always plan for
rapid escape when they venture outside. Agoraphobia may be characterized either by
avoiding the situations or by enduring them with intense fear and anxiety.
Most patients with panic disorder and agoraphobic avoidance also display interoceptive
avoidance, which are behaviors that involve removing oneself from situations or activities
that might produce the physiological arousal that somehow resemble the beginnings of a
panic attack.
Table 5.3 Diagnostic Criteria for Panic Disorder
A. Recurrent or unexpected panic attacks are present
B. At least one of the attacks has been followed by 1 month or more of one or both of the
following:
1. Persistent concern or worry about additional panic attacks or their
consequences; or
2. A significant maladaptive change in behavior related to the attacks
C. The disturbance is not attributable to the physiological effects of a substance or
another medical condition
D. The disturbance Is not better explained by another mental disorder
Table 5.4 Diagnostic Criteria for Agoraphobia
A. Marked fear or anxiety about two or more of the following five situations:
1. Public transportations
2. Open spaces
3. Enclosed places
4. Standing in line or being in a crowd
5. Being outside the home alone
B. The individual fears or avoids these situations due to thoughts that escape might be
difficult or help might not be available in the event of developing panic-like symptoms
or other incapacitating or embarrassing symptoms
C. The agoraphobic situations almost always provoke fear or anxiety
D. The agoraphobic situations are actively avoided, require the presence of a companion,
or are endured with intense fear or anxiety
E. The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic
situations, and to the sociocultural context
F. The fear, anxiety or avoidance is persistent, typically lasting for 6 months or more
G. The fear, anxiety or avoidance causes clinically significant distress or impairment in
social, occupational or other important areas of functioning
H. If another medical condition is present, the fear, anxiety or avoidance is clearly
excessive
I. The fear, anxiety or avoidance is not better explained by the symptoms of another
mental disorder, e.g., the symptoms are not confided to specific phobia, situational
type; do not involve only social situations and are not related exclusively to
obsessions, perceived deficits or flaws in physical appearance, reminders of traumatic
events, or fear of separation
STATISTICS
 Panic Disorder is fairly common and 2/3 of them are women. Onset of panic disorder
usually occurs in early adult life (midteens – 40 years of age). Most initial unexpected
panic attacks begin at or after puberty.
 In general, the prevalence or comorbid panic disorder and agoraphobia decreases among
the elderly.
 Panic attacks occur more often between 1:30 am and 3:30 an, than any other time.
Nocturnal panic attacks occur during delta wave or slow wave sleep, the deepest stage
of sleep. Most of these individuals think they are dying. People are not dreaming when
they have a nocturnal panic.
CAUSES
 Agoraphobia often develops after a person has unexpected panic attacks, but whether
agoraphobia develops and how severe it becomes seem to be socially and culturally
determined.
 Panic attacks and panic disorder seem to be more related most strongly to biological and
physiological factors and their interaction.
 Women who had a history of various physical disorders and were anxious about their
health tended to develop panic disorder rather than another anxiety disorder. They may
have learned in childhood that unexpected bodily sensations may be dangerous, this
tendency to believe that unexpected bodily sensations are dangerous reflects a specific
psychological vulnerability to develop panic and related disorders.
TREATMENT
 Medication: Drugs affecting the noradrenergic, serotonergic, or GABA – benzodiazepine
neurotransmitter systems, or some combination, seem effective in treating panic
disorder, including high-potency benzodiazepines, the newer selective-serotonin
reuptake inhibits (SSRIs). Benzodiazepines remain the most widely used class of drugs
in practice.
 Psychological Interventions: Psychological treatments have proved quite effective for
panic disorder. The strategy of exposure-based treatments is to arrange conditions in
which the patient can gradually face the feared situations and learn there is nothing to
fear. Patients are taught relaxation or breathing retraining to help them reduce anxiety
and excess arousal. Nevertheless, some people relapse over time.
 Combined Treatment: Combined treatments was no better than individual treatments.
Treatments containing CBT without the drug tended to be superior at this point,
because they and more enduring effects.
In conclusion, psychological treatment seemed to perform better in the long run (6 months
after treatment had stopped).
(3) SPECIFIC PHOBIA
CLINICAL DESCRIPTIONS
A specific phobia is an irrational fear of a specific object or situation that markedly
interferes with an individual’s ability to function. People can adapt to life with a phobia by
simply working around it somehow.
Table 5.5 Diagnostic Criteria for Specific Phobia
A. Marked fear or anxiety about a specific object or situation (e.g., flying, heights,
animals)
B. The phobic object or situation almost always provokes immediate fear or anxiety.
Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or
clinging
C. The phobic object or situations is actively avoided or endured with intense fear or
anxiety
D. The fear or anxiety is out of proportion to the actual danger posed by the specific
object or situation, and to the sociocultural context
E. The fear, anxiety or avoidance is persistent, typically lasting for 6 months or more
F. The fear, anxiety, or avoidance causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning
G. The disturbance is not better explained by the symptoms of another mental disorder,
including fear, anxiety and avoidance of situation associated with panic-like
symptoms or other incapacitating symptoms; objects or situations are related to
obsessions; reminders of traumatic events; separation from home or attachment
figures; or social situations
Specify type:
Animal, Natural Environment, Blood-injection-injury, Other
There are four major subtypes of specific phobias, which are:
1. Blood-Injection-Injury Phobia: People with this phobia almost always differ in their
physiological reaction from other people with other types of phobias. It runs in the
families more strongly than any other phobic disorder we know. The average onset for
this phobia is approximately 9 years.
2. Situational Phobia: These are phobias characterized by fear of public transportation or
enclosed space. Tends to emerge from midteens to mid-20s. People with situational
phobia never experience panic attacks outside the context of their phobic object or
situation.
3. Natural Environment: The major examples are heights, storms, and water. They have to
be persistent and to interfere substantially with the person’s functioning, leading to
avoidance. Peak age of onset is about 7 years.
4. Animal Phobia: Age of onset peaks around 7 years.
STATISTICS
Sex ratios among common fear is overwhelmingly female. Specific phobia is one of the most
common psychological disorders around the world. Once a phobia develops, it tends to last a
lifetime (runs a chronic course).
CAUSES
 Can be acquired through direct experience, where real danger or pain results in an
alarm response (a true alarm); experiencing a false alarm (panic attack) in a specific
situation; observing someone else experiencing severe fear (vicarious experience); or
under the right conditions, being told about danger.
 Several things have to occur for a person to develop a phobia. First, a traumatic
conditioning experience often plays a role. Second, fear is more likely to develop if we are
“prepared”, which means we carry an inherited tendency to fear situations that have
always been dangerous to the human race. Third, we have to be susceptible to
developing anxiety about the possibility that the events will happen again.
 Social and cultural factors are strong determinants of who develops and reports a
specific phobia. The overwhelming majority of reported specific phobias occur to women.
TREATMENT
Specific phobias require structured and consistent exposure-based exercises.
SEPARATION ANXIETY DISORDER
Separation Anxiety Disorder is characterized by children’s unrealistic and persistent worry
that something will happen to their parents or other important people in their life or that
something will happen to the children themselves that will separate them from their parents.
4.1% of children have separation anxiety at a severe enough level to meet criteria for a
disorder. Separation anxiety, if untreated, can extend into adulthood in approximately 35% of
cases.
Diagnostic Criteria for Separation Anxiety Disorder
A. Developmentally inappropriate and excessive fear or anxiety concerning separation
from those to whom the individual is attached, as evidenced by at least three of the
following:
1. Recurrent excessive distress when anticipating or experiencing separation from
home or from major attachment figures.
2. Persistent and excessive worry about losing major attachment figures or about
possible harm to them, such as illness, injury, disasters, or death.
3. Persistent and excessive worry about experiencing an untoward event (e.g.,
getting lost, being kidnapped, having an accident, becoming ill) that causes
separation from a major attachment figure.
4. Persistent reluctance or refusal to go out, away from home, to school, to work, or
elsewhere because of fear of separation.
5. Persistent and excessive fear or reluctance about being alone or without major
attachment figures at home or in other settings.
6. Persistent reluctance or refusal to sleep away from home or to go to sleep without
being near a major attachment figure.
7. Repeated nightmares involving the theme of separation.
8. Repeated complaints of physical symptoms (e.g., headaches, stomachaches,
nausea, vomiting) when separation from major attachment figures occurs or is
anticipated.
B. The fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in children and
adolescents and typically 6 months or more in adults.
C. The disturbance causes clinically significant distress or impairment in social,
academic, occupational, or other important areas of functioning.
D. The disturbance is not better explained by another mental disorder, such as refusing
to leave home because of excessive resistance to change in autism spectrum disorder;
delusions or hallucinations concerning separation in psychotic disorders; refusal to
go outside without a trusted companion in agoraphobia; worries about ill health or
other harm befalling significant others in generalized anxiety disorder; or concerns
about having an illness in illness anxiety disorder.
(4) SOCIAL ANXIETY DISORDER (SAD)/SOCIAL PHOBIA
CLINICAL DESCRIPTIONS
Table 5.6 Diagnostic Criteria for Social Anxiety Disorder
A. Marked fear or anxiety about one or more social situations in which the individual is
exposed to possible scrutiny by others. Examples include social interactions (e.g.,
having a conversation, meeting unfamiliar people), being observed (e.g., eating or
drinking), and performing in front of others (e.g., giving a speech).
Note: In children, the anxiety must occur in peer settings and not just during
interactions with adults
B. The individual fears that he or she will act in a way or show anxiety symptoms that
will be negatively evaluated (i.e., will be humiliating or embarrassing; will lead to
rejection or offend others).
C. The social situations almost always provoke fear or anxiety.
Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing,
clinging, shrinking, or failing to speak in social situations.
D. The social situations are avoided or endured with intense fear or anxiety.
E. The ear or anxiety is out of proportion to the actual threat posed by the social
situation and to the sociocultural context.
F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
H. The fear, anxiety, or avoidance is not attributable to the physiological effects of a
substance (e.g., a drug of abuse, a medication) or another medical condition.
I. The fear, anxiety, or avoidance is not better explained by the symptoms of another
mental disorder, such as panic disorder, body dysmorphic disorder, or autism
spectrum disorder.
J. If another medical condition (e.g., Parkinson’s disease, obesity, disfigurement from
burns or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is
excessive.
Specify if:
Performance only: If the fear is restricted to speaking or performing in public.
STATISTICS
12.1% of the general population suffer from SAD at some point in their lives. SAD is second
phobia that is most prevalent in anxiety disorder. The sex ration is 50:50. It usually begins
during adolescence, with a peak age of onset around 13 years. It is prevalent in people who
are young.
Taijin kyufusho – the key feature is preoccupation with a belief that one is embarrassing  Difficulty sleeping and recurring intrusive dreams of the event are prominent features of
oneself and offending others with a foul body odor. PTSD
 The diagnosis of PTSD cannot be made until at least one month after the occurrence of
CAUSES the traumatic event.
 It seems that we are prepared to fear angry, critical, or rejecting people. Socially anxious  In PTSD with delayed onset, individuals show few or no symptoms immediately or for
individuals more quickly recognized angry faces than normal. They react to angry faces months after a trauma, but at least 6 months later, and perhaps years afterwards,
with greater activation of the amygdala and less cortical control or regulation. Eye region develop a full-blown PTSD
is the threatening area of the face.
 Someone could inherit a generalized biological vulnerability to develop anxiety, a
biological tendency to be socially inhibited, or both. When under stress, someone might
have an unexpected panic attack in social situation that would become associated
(conditioned) to social cues. Someone might experience a real social trauma resulting in
a true alarm. The individual with the vulnerability must also have learned growing up
that social evaluation in particular can be dangerous.

TREATMENT
 Effective treatments have been developed for SAD which is the cognitive therapy program Table 5.7 Diagnostic Criteria for Posttraumatic Stress Disorder
that emphasized real-life experiences during therapy to disprove automatic perceptions
A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or
of danger.
more) of the following ways:
 Family-based intervention can even prevent then onset of anxiety disorders in the 1. Directly experiencing the traumatic event(s).
children of anxious parents. 2. Witnessing, in person, the event(s) as it occurred to others.
 SSRIs, Paxil, Zoloft, and Effexor showed effectiveness and received approval from FDA. 3. Learning that the traumatic event(s) occurred to a close family member or
 Psychological treatment was better at all times, with most patients cured or nearly cured close friend. In cases of actual or threatened death of a family member or friend,
with few remaining symptoms. Gains using cognitive therapy were maintained when the event(s) must have been violent or accidental.
assessed after 5 years. 4. Experiencing repeated or extreme exposure to aversive details of the traumatic
event(s) (e.g., first responders collecting human remains; police officers
SELECTIVE MUTISM repeatedly exposed to details of child abuse).
Diagnostic Criteria for Selective Mutism Note: Criterion A4 does not apply to exposure through electronic media,
A. Consistent failure to speak in specific social situations in which there is an television, movies, or pictures, unless this exposure is work related.
expectation for speaking (e.g., at school) despite speaking in other situations. B. Presence of one (or more) of the following intrusion symptoms associated with the
B. The disturbance interferes with educational or occupational achievement or with traumatic event(s), beginning after the traumatic event(s) occurred:
social communication. 1. Recurrent, involuntary, and intrusive distressing memories
C. The duration of the disturbance is at least 1 month (not limited to the first month of of the traumatic event(s).
school). Note: In children older than 6 years, repetitive play may occur in which themes
D. The failure to speak is not attributable to a lack of knowledge of, or comfort with, the or aspects of the traumatic event(s) are expressed.
spoken language required in the social situation. 2. Recurrent distressing dreams in which the content and/or affect of the dream
E. The disturbance is not better explained by a communication are related to the traumatic event(s).
disorder (e.g., childhood onset fluency disorder) and does not Note: In children, there may be frightening dreams without recognizable content.
occur exclusively during the course of autism spectrum 3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as
disorder, schizophrenia, or another psychotic disorder if the traumatic event(s) were recurring. (Such reactions may occur on a
continuum, with the most extreme expression being a complete loss of awareness
Selective mutism is a rare childhood disorder characterized by a lack of speech in one or of present surroundings.)
more settings in which speaking is socially expected. It seems clearly driven by social anxiety. Note: In children, trauma-specific reenactment may occur in play.
4. Intense or prolonged psychological distress at exposure to internal or external
TRAUMA AND STRESSOR-RELATED DISORDERS cues that symbolize or resemble an aspect of the traumatic event(s).
5. Marked physiological reactions to internal or external cues that symbolize or
resemble an aspect of the traumatic event(s).
(1) POSTTRAUMATIC STRESS DISORDER (PTSD) C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after
CLINICAL DESCRIPTIONS the traumatic event(s) occurred, as evidenced by one or both of the following:
 One can develop PTSD through exposure to a traumatic event during which an 1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings
individual experiences or witnesses’ death or threatened death, actual or threatened about or closely associated with the traumatic event(s).
serious injury, or actual or threatened sexual violation. 2. Avoidance of or efforts to avoid external reminders (people, places,
 Victims reexperience the event through memories and nightmares (flashbacks). They conversations, activities, objects, situations) that arouse distressing memories,
often avoid anything that reminds them of the trauma. thoughts, or feelings about or closely associated with the traumatic event(s).
 Victims are chronically over aroused, easily startled, and quick to anger. D. Negative alterations in cognitions and mood associated with the traumatic event(s),
 beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or
more) of the following:
1. Inability to remember an important aspect of the traumatic event(s) (typically
due to dissociative amnesia and not to other factors such as head injury, alcohol,
or drugs).
2. Persistent and exaggerated negative beliefs or expectations about oneself,
others, or the world (e.g., “I am bad,” “No one can be trusted,” “The world is
completely dangerous,” “My whole nervous system is permanently ruined”).
3. Persistent, distorted cognitions about the cause or consequences of the
traumatic event(s) that lead the individual to blame himself/herself or others.
4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
5. Markedly diminished interest or participation in significant activities.
6. Feelings of detachment or estrangement from others.
7. Persistent inability to experience positive emotions (e.g., inability to experience
happiness, satisfaction, or loving feelings).
E. Marked alterations in arousal and reactivity associated with the traumatic event(s),
beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or
more) of the following:
1. Irritable behavior and angry outbursts (with little or no provocation) typically
expressed as verbal or physical
aggression toward people or objects.
2. Reckless or self-destructive behavior.
3. Hypervigilance.
4. Exaggerated startle response.
5. Problems with concentration.
6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).
F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.
G. The disturbance causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
H. The disturbance is not attributable to the physiological effects of a substance (e.g.,
medication, alcohol) or another medical condition.
Specify whether:
With dissociative symptoms: The individual’s symptoms meet the criteria for
posttraumatic stress disorder, and in addition, in response to the stressor, the individual
experiences persistent or recurrent symptoms of either of the following:
1. Depersonalization: Persistent or recurrent experiences of feeling detached
from, and as if one were an outside observer of, one’s mental processes or body
(e.g., feeling as though one were in a dream; feeling a sense of unreality of self or
body or of time moving slowly).
2. Derealization: Persistent or recurrent experiences of unreality of
surroundings (e.g., the world around the individual is experienced as unreal,
dreamlike, distant, or distorted).
Note: To use this subtype, the dissociative symptoms must not be attributable to the
physiological effects of a substance (e.g., blackouts, behavior during alcohol intoxication)
or
another medical condition (e.g., complex partial seizures).
Specify if:
With delayed expression: If the full diagnostic criteria are not met until at least 6 months
after the event (although the onset and expression of some symptoms may be immediate).
STATISTICS
Close exposure to the trauma seems to be necessary to developing this disorder. Those who
experienced the disaster most personally and directly seemed to be the ones most affected.
Change in PTSD symptoms may be due to individual difference in resiliency, coping skills,
levels of trauma exposure, early adversities, ongoing stress, and even the presence of mild
traumatic brain injuries.
CAUSES
Someone personally experiencing a trauma and develops a disorder. Intensity of exposure to
assaultive violence contributes to the etiology of PTSD. The greater the vulnerability, the
more likely we are to develop PTSD.
TREATMENT
Imaginal exposure – content of the trauma and the emotions associated with it are worked
through systematically.
ACUTE STRESS DISORDERS
Diagnostic Criteria for Acute Stress Disorders
A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the
following ways:
1. Directly experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as it occurred to others.
3. Learning that the event(s) occurred to a close family member or close friend. Note: In cases of
actual or threatened death of a family member or friend, the event(s) must have been violent or
accidental.
4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g.,
first responders collecting human remains, police officers repeatedly
exposed to details of child abuse).
Note: This does not apply to exposure through electronic media, television, movies, or pictures,
unless this exposure is work related.
B. Presence of nine (or more) of the following symptoms from any of the five categories of intrusion,
negative mood, dissociation, avoidance, and arousal, beginning or worsening after the traumatic
event(s) occurred:
Intrusion Symptoms
1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: In
children, repetitive play may occur in which themes or aspects of the traumatic event(s) are
expressed.
2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the
event(s).
Note: In children, there may be frightening dreams without recognizable content.
3.Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic
event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme
expression being a complete loss of awareness of present surroundings.) Note: In children,
trauma-specific reenactment may occur in play.
4. Intense or prolonged psychological distress or marked physiological reactions in response to
internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
Negative Mood
5. Persistent inability to experience positive emotions (e.g., inability to experience happiness,
satisfaction, or loving feelings).
Dissociative Symptoms
6. An altered sense of the reality of one’s surroundings or oneself (e.g., seeing oneself from
another’s perspective,being in a daze, time slowing).
7. Inability to remember an important aspect of the traumatic event(s) (typically due to
dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).
Avoidance Symptoms
8. Efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the
traumatic event(s).
9. Efforts to avoid external reminders (people, places, conversations, activities, objects, situations)
that arouse distressing memories, thoughts, or feelings about or closely associated with the
 traumatic event(s). months after the termination of the stressor or its consequences. The persistent
Arousal Symptoms specifier therefore applies when the duration of the disturbance is longer than 6
10. Sleep disturbance (e.g., difficulty falling or staying asleep, restless sleep). months in response to a chronic stressor or to a stressor that has enduring
11. Irritable behavior and angry outbursts (with little or no provocation), typically expressed as
verbal or physical aggression toward people or objects.
consequences.
12. Hypervigilance.
13. Problems with concentration. ATTACHMENT DISORDER
14. Exaggerated startle response. Attachment disorder refers to disturbed and developmentally inappropriate behavior in
C. Duration of the disturbance (symptoms in Criterion B) is 3 days to 1 month after trauma children, emerging before five years of age, in which the child is unable or unwilling to form
exposure. normal attachment relationships with caregiving adults.
Note: Symptoms typically begin immediately after the trauma, but persistence for at least 3 days
and up to a month is needed to meet disorder criteria.
D. The disturbance causes clinically significant distress or impairment in social, occupational, or In reactive attachment disorder, the child will very seldom seek out a caregiver for protection,
other important areas of functioning. support, and nurturance, and will seldom respond to offers from caregivers to provide this
E. The disturbance is not attributable to the physiological effects of a substance (e.g., medication or kind of care.
alcohol) or another medical condition (e.g., mild traumatic brain injury) and is not better
explained by brief psychotic disorder. In disinhibited social engagement disorder, the child shows no inhibitions whatsoever to
approaching adults.

ADJUSTMENT DISORDER
Diagnostic Criteria for Adjustment Disorder OBSESSIVE-COMPULSIVE DISORDER
A. The development of emotional or behavioral symptoms in response to an identifiable Diagnostic Criteria for Obsessive-Compulsive Disorder
stressor(s) occurring within 3 months of the onset of the stressor(s). A. Presence of obsessions, compulsions, or both:
B. These symptoms or behaviors are clinically significant, as evidenced by one or both of
the following: Obsessions are defined by (1) and (2):
1. Marked distress that is out of proportion to the severity or intensity of the stressor, 1. Recurrent and persistent thoughts, urges, or images that are experienced, at some
taking into account the external context and the cultural factors that might influence time during the disturbance, as intrusive and unwanted, and that in most individuals
symptom severity and presentation. cause marked anxiety or distress.
2. Significant impairment in social, occupational, or other important areas of 2. The individual attempts to ignore or suppress such thoughts, urges, or images, or
functioning. to neutralize them with some other thought or action (i.e., by performing a
C. The stress-related disturbance does not meet the criteria for another mental disorder compulsion).
and is not merely an exacerbation of a preexisting mental disorder. Compulsions are defined by (1) and (2):
D. The symptoms do not represent normal bereavement and are not better explained by 1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g.,
prolonged grief disorder. praying, counting, repeating words silently) that the individual feels driven to perform
E. Once the stressor or its consequences have terminated, the symptoms do not persist in response to an obsession or according to rules that must be applied rigidly.
for more than an additional 6 months. 2. The behaviors or mental acts are aimed at preventing or reducing anxiety or
distress, or preventing some dreaded event or situation; however, these behaviors or
Specify whether: mental acts
F43.21 With depressed mood: Low mood, tearfulness, or feelings of hopelessness are not connected in a realistic way with what they are designed to neutralize or
are predominant. prevent, or are clearly excessive.
F43.22 With anxiety: Nervousness, worry, jitteriness, or separation anxiety is Note: Young children may not be able to articulate the aims of these behaviors or
predominant. mental acts.
F43.23 With mixed anxiety and depressed mood: A combination of depression and B. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per
anxiety is predominant. day) or cause clinically significant distress or impairment in social, occupational, or
F43.24 With disturbance of conduct: Disturbance of conduct is predominant. other important areas of functioning.
F43.25 With mixed disturbance of emotions and conduct: Both emotional C. The obsessive-compulsive symptoms are not attributable to the physiological effects of
symptoms (e.g., depression, anxiety) and a disturbance of conduct are predominant. a substance (e.g., a drug of abuse, a medication) or another medical condition.
F43.20 Unspecified: For maladaptive reactions that are not classifiable as one of the D. The disturbance is not better explained by the symptoms of another mental disorder
specific subtypes of adjustment disorder. (e.g., excessive worries, as in generalized anxiety disorder; preoccupation with
appearance, as in body dysmorphic disorder; difficulty discarding or parting with
Specify if: possessions, as in hoarding disorder; hair pulling, as in trichotillomania [hair-pulling
Acute: This specifier can be used to indicate persistence of disorder]; skin picking, as in excoriation [skin-picking] disorder; stereotypies, as in
symptoms for less than 6 months. stereotypic movement disorder; ritualized eating behavior, as in eating disorders;
preoccupation with substances or gambling, as in substance-related and addictive
Persistent (chronic): This specifier can be used to indicate persistence of symptoms disorders; preoccupation with having an illness, as in illness anxiety disorder; sexual
for 6 months or longer. By definition, symptoms cannot persist for more than 6
 urges or fantasies, as in paraphilic disorders; impulses, as in disruptive, impulse-
control, and conduct disorders; guilty ruminations, as in major depressive disorder;
thought insertion or delusional preoccupations, as in schizophrenia spectrum and
other psychotic disorders; or repetitive patterns of behavior, as in autism spectrum
disorder).
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 obsessive-compulsive disorder beliefs are
probably true.
With absent insight/delusional beliefs: The individual is completely convinced that
obsessive-compulsive disorder beliefs are true.
Specify if:
Tic-related: The individual has a current or past history of a tic disorder.
STATISTICS DISORDER
OCD has a ratio of female to male that is nearly 1:1. Boys tend to develop OCD earlier.
BODY DYSMORPHIC DISORDER
Diagnostic Criteria for Obsessive-Compulsive Disorder
A. Preoccupation with one or more perceived defects or flaws in physical appearance
that are not observable or appear slight to others.
B. At some point during the course of the disorder, the individual has performed
repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking,
reassurance seeking) or mental acts (e.g., comparing his or her appearance with that
of others) in response to the appearance concerns.
C. The preoccupation causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
D. The appearance preoccupation is not better explained by concerns with body fat or
weight in an individual whose symptoms meet diagnostic criteria for an eating
disorder.
Specify if:
With muscle dysmorphia: The individual is preoccupied with the idea that his or her
body build is too small or insufficiently muscular. This specifier is used even if the
individual is preoccupied with other body areas, which is often the case.
Specify if:
Indicate degree of insight regarding body dysmorphic disorder beliefs (e.g., “I look ugly” or
“I look deformed”).
With good or fair insight: The individual recognizes that the body dysmorphic disorder
beliefs are definitely or probably not true or that they may or may not be true.
With poor insight: The individual thinks that the body dysmorphic disorder beliefs are
probably true
With absent insight/delusional beliefs: The individual is
completely convinced that the body dysmorphic disorder beliefs are true.
HOARDING DISORDER
Diagnostic Criteria for Hoarding Disorder
A. Persistent difficulty discarding or parting with possessions, regardless of their actual
value.
B. This difficulty is due to a perceived need to save the items and to distress associated
with discarding them.
C. The difficulty discarding possessions results in the accumulation of possessions that
congest and clutter active living areas and substantially compromises their intended
use. If living areas are uncluttered, it is only because of the interventions of third
parties (e.g., family members, cleaners, authorities).
D. The hoarding causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning (including maintaining a safe
environment for self and others).
E. The hoarding is not attributable to another medical condition (e.g., brain injury,
cerebrovascular disease, Prader-Willi syndrome).
F. The hoarding is not better explained by the symptoms of another mental disorder
(e.g., obsessions in obsessive-compulsive disorder, decreased energy in major
depressive disorder, delusions in schizophrenia or another psychotic disorder,
cognitive deficits in major neurocognitive disorder, restricted interests in autism
spectrum disorder).
Specify if:
With excessive acquisition: If difficulty discarding possessions is accompanied by
excessive acquisition of items that are not needed or for which there is no available space.
Specify if:
With good or fair insight: The individual recognizes that hoarding-related beliefs and
behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are
problematic.
With poor insight: The individual is mostly convinced that hoarding-related beliefs and
behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are
not problematic despite evidence to the contrary.
With absent insight/delusional beliefs: The individual is completely convinced that
hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or
excessive acquisition) are not problematic despite evidence to the contrary.
TRICHOTILLOMANIA (HAIR-PULLING DISORDER)
Diagnostic Criteria for Trichotillomania
A. Recurrent pulling out of one’s hair, resulting in hair loss.
B. Repeated attempts to decrease or stop hair pulling.
C. The hair pulling causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
D. The hair pulling or hair loss is not attributable to another medical condition (e.g., a
dermatological condition).
E. The hair pulling is not better explained by the symptoms of another mental disorder
(e.g., attempts to improve a perceived defect or flaw in appearance in body
dysmorphic disorder)
EXCORIATION (SKIN-PICKING DISORDER)
Diagnostic Criteria for Excoriation
A. Recurrent skin picking resulting in skin lesions.
B. Repeated attempts to decrease or stop skin picking.
C. The skin picking causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
D. The skin picking is not attributable to the physiological effects of a substance (e.g.,
cocaine) or another medical condition (e.g., scabies).
E. The skin picking is not better explained by symptoms of another mental disorder (e.g.,
delusions or tactile hallucinations in a psychotic disorder, attempts to improve a
perceived defect or flaw in appearance in body dysmorphic disorder, stereotypies in
stereotypic movement disorder, or intention to harm oneself in nonsuicidal self-
injury).
CHAPTER 6: SOMATIC SYMPTOMS AND RELATED DISORDERS AND
DISSOCIATIVE DISORDERS
SOMATIC SYMPTOM AND RELATED DISORDERS
Hypochondriac is someone who exaggerates the slightest physical symptoms. For a few
individuals, the preoccupation with their health or appearance becomes so great that it
dominates their lives. Their problem falls under the general heading of somatic symptom
disorders. In some cases, the medical cause of the presenting physical symptoms is known
but the emotional distress or level of impairment in response to this symptom is clearly
excessive and may even make the condition worse.
DSM-5 lists five basic somatic symptoms and related disorders: somatic symptom disorder,
illness anxiety disorder, psychological factors affecting medical condition, conversion
disorder, and factitious disorder. In each, individuals are pathologically concerned with the
functioning of their bodies.
1. SOMATIC SYMPTOM DISORDER
This disorder was once called Briquet’s syndrome, from a French physician Pierre Briquet
who had a patient with seemingly endless lists of somatic complaints. People with somatic
symptom disorder do not always feel the urgency to take actions but continually feel weak
and ill, and they avoid exercising thinking it will make them worse.
Another example of a somatic symptom disorder would be the experience of severe pain in
which psychological factors play a major role in maintaining or exacerbating the pain
whether there is a clear physical reason for the pain or not.
The important factor in this condition is not whether the physical symptom, for example
pain, has a clear medical cause or not, but rather that psychological or behavioral factors,
particularly anxiety and distress, are compounding the severity and impairment associated
with the physical symptoms. These physical symptoms, such as pain, is that it is real and it
hurts whether there is clear physical reason for pain or not.
Diagnostic Criteria for Somatic Symptom Disorder (F45.1)
A. One or more somatic symptom that are distressing or result in significant disruption
of daily life.
B. Excessive thoughts, feelings, and behavior related to the somatic symptoms or
associated health concerns as manifested by at least one of the following:
1. Disproportionate and persistent thoughts about the seriousness of one’s
symptoms.
2. Persistently high level of anxiety about health or symptoms.
3. Excessive time and energy devoted to these symptoms or health concerns.
C. Although any one somatic symptom may not be continuously present, the state of
being symptomatic is persistent (typically more than 6 months).
Specify if:
With predominant pain (previously pain disorder): This specifier is for individuals
whose somatic complaints predominantly involve pain.
Specify if:
Persistent: A persistent course is characterized by severe symptom, marked impairment,
and long duration (more than 6 months)
Specify current severity:
Mild: Only one of the symptoms specified in Criterion B is fulfilled.
Moderate: Two or more of the symptoms specified in Criterion B are fulfilled.
Severe: Two or more of the symptoms specified in Criterion B are fulfilled, plus there are
multiple somatic complaints (or one very severe somatic symptoms).
2. ILLNESS ANXIETY DISORDER
Formerly known as hypochondriasis. Physical symptoms are either not experienced at the
present time or are very mild, but severe anxiety is focused on the possibility of having or
developing a serious disease. The primary concern is with the idea of being sick instead of the
physical symptom itself. The threat seems so real that reassurance from physician does not
seem to help.
CLINICAL DESCRIPTION
Anxiety and mood disorders are often comorbid with somatic symptom disorders. The essential
problem is anxiety, but its expression is different from that of the other anxiety disorders. The
individual is preoccupied with bodily symptoms, misinterpreting them as indicative of illness or
disease. Almost any physical sensation may become the basis for concerns.
Reassurances from numerous doctors that all is well and the individual is healthy have, at beast,
only a short-term effect. Along with anxiety focused on the possibility of disease or illness, disease
conviction (individuals mistakenly believe they have a disease, a difficult-to-shake belief) is a core
feature of the disorder.
Diagnostic Criteria for Illness Anxiety Disorder (F45.21)
A. Preoccupation with having or acquiring a serious illness
B. Somatic symptoms are not present or, if present, are only mild in intensity. If another
medical condition is present or there is a high risk for developing a medical condition
(e.g., strong family history is present), the preoccupation is clearly excessive or
disproportionate.
C. There is a high level of anxiety about health, and the individual is easily alarmed
about personal health status.
D. The individual performs excessive health-related behaviors (e.g., repeatedly checks his
or her body for signs of illness) or exhibits maladaptive avoidance (e.g., avoids doctor
appointment and hospitals)
E. Illness preoccupation has been present for at least 6 months, but the specific illness
that is feared may change over that period of time.
F. The illness-related preoccupation is not better explained by another mental disorder,
such as somatic symptom disorder, panic disorder, generalized anxiety disorder, body
dysmorphic disorder, obsessive-compulsive disorder, or delusional disorder, somatic
type.
Specify whether:
Care-seeking type: Medical care, including physician visits or undergoing tests and
procedures, is frequently used.
Care-avoidant type: Medical care is rarely used
STATISTICS
A number of studies have demonstrated that individuals suffering from somatic symptom disorder
tend to be women, unmarried, and from lower socioeconomic disorders. In addition to a variety of
somatic complaints, individuals may have psychological complaints, usually anxiety or mood
disorders. Individuals with somatic symptom disorders overuse and misuse the health-care system,
with medical bills as much as 9 times more than the average patient.
CAUSES
Individuals with somatic symptom disorder experience physical sensations common to all pf us, but
they quickly focus their attention on these sensations. (1) These disorders seem to develop in the
context of a stressful life event; (2) People who develop these disorders tend to have had a
disproportionate incidence of disease in their family when they were children; and (3) an important
social and interpersonal influence may be involved. Treatments for these can be Cognitive-
Behavior Therapy (CBT) and/or drug treatments (the same type of drugs used for anxiety and
depression).
3. PSYCHOLOGICAL FACTORS AFFECTING MEDICAL CONDITION
The essential feature of this disorder is the presence of a diagnosed medical conditions
caused by a known medical condition that is adversely affected by one or more psychological
or behavioral factors. These behavioral or psychological factors would have a direct influence
on the course or perhaps the treatment of the medical condition.
Diagnostic Criteria for Psychological Factors Affecting Other Medical Conditions
(F54)
A. A medical symptom or condition (other than a mental disorder) is present.
B. Psychological or behavioral factors adversely affect the medical condition in one of the
following ways:
1. The factors have influenced the course of the medical condition as shown by a
close temporal association between the psychological factors and the
development or exacerbation of, or delayed recovery from, the medical condition.
2. The factors interfere with the treatment of the medical condition (e.g., poor
adherence).
3. The factors constitute additional well-established health risks for the individual.
4. The factors influence the underlying pathophysiology, precipitating or
exacerbating symptoms or necessitating medical attention.
C. The psychological and behavioral factors in Criterion B are not better explained by
another mental disorder (e.g., panic disorder, major depressive disorder,
posttraumatic stress disorder).
Specify current severity:
Mild: Increased medical risk (e.g., inconsistent adherence with antihypertension
treatment).
Moderate: Aggravates underlying medical condition (e.g., anxiety aggravating asthma).
Severe: Results in medical hospitalization or emergency room visit.
Extreme: Results in severe, life-threatening risk (e.g., ignoring heart attack symptoms).
4. CONVERSION DISORDER (FUNCTIONAL NEUROLOGICAL SYMPTOM
DISORDER)
The term ‘conversion’ was popularized by Freud, who believed the anxiety resulting from
unconscious conflicts somehow was converted into physical symptoms to find expression.
This allowed the individual to discharge some anxiety without actually experiencing it.
‘Functional’ refers to a symptom without an organic cause.
Diagnostic Criteria for Conversion Disorder (Functional Neurological Symptom
Disorder)
A. One or more symptoms of altered voluntary motor or sensory function.
B. Clinical findings provide evidence of incompatibility between the symptom and
recognized neurological or medical conditions.
C. The symptom or deficit is not better explained by another medical or mental disorder.
D. The symptom or deficit causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning or warrants medical evaluation.
Specify if:
Acute episode: Symptoms present for less than 6 months.
Persistent: Symptoms occurring for 6 months or more.
Specify if:
With psychological stressor (specify stressor)
Without psychological stressor
CLINICAL DESCRIPTION
Conversion disorders generally have to do with physical malfunctioning, such as paralysis,
blindness, or difficulty speaking, without any physical or organic pathology to account for the
malfunction.
5. FACTITIOUS DISORDER
Factitious disorders, fall somewhere between malingering and conversion disorder. The
symptoms are under voluntary control, but there is no obvious reason for voluntarily
producing the symptoms except, possibly, to assume the sick role and receive increased
attention. When an individual deliberately makes someone else sick, the condition is called
factitious disorder imposed on another, which is really an atypical form of child abuse.
The offending parent may resort to extreme tactics to create the appearance of illness in the
child.
Diagnostic Criteria
FACTITIOUS DISORDER IMPOSED ON SELF (F68.10)
A. Falsification of physical or psychological signs or symptoms, or induction of injury or
disease, associated with identified deception.
B. The individual presents himself or herself to others as ill, impaired, or injured.
C. The deceptive behavior is evident even in the absence of obvious external rewards.
D. The behavior is not better explained by another mental disorder, such as delusional
disorder or another psychotic disorder.
Specify:
Single episode
Recurrent episodes (two or more events or falsification of illness and/or induction of
injury)
FACTITIOUS DISORDER IMPOSED ON ANOTHER (F68.A)
A. Falsification of physical or psychological signs or symptoms, or induction of injury or
disease, in another, associated with identified deception.
B. The individual presents another individual (victim) to others as ill, impaired, or
injured.
C. The deceptive behavior is evident even in the absence of obvious external rewards.
D. The behavior is not better explained by another mental disorder, such as delusional
disorder or another psychotic disorder.
Note: The perpetrator, not the victim, receives this diagnosis.
Specify:
Single episode
Recurrent episodes (two or more events or falsification of illness and/or induction of
injury)
CHAPTER 14: SCHIZOPHRENIA SPECTRUM AND OTHER PSYCHOTIC
DISORDERS
Schizophrenia spectrum and other psychotic disorders include schizophrenia, other
psychotic disorders, and schizotypal (personality) disorder. They are defined by abnormalities
in one or more of the following five domains: delusions, hallucinations, disorganized
thinking (speech), grossly disorganized or abnormal motor behavior (including
catatonia), and negative symptoms.

Schizophrenia…
 a complex syndrome which is characterized by a broad spectrum of cognitive and
emotional dysfunctions including delusions and hallucinations, disorganized speech
and behavior, and inappropriate emotion
 full recovery from schizophrenia has a low base rate of 1 in 7 patients
 so widespread affecting approximately 1 of every 100 people at some point in their
lives
 the nature of the disorder is multifaceted and treatment is correspondingly complex

EARLY FIGURES IN DIAGNOSING SCHIZOPHRENIA

Toward the end of 19th century, German psychiatrist Emil Kraepelin built on the writings of
Hasiam, Pinel, and Moral (among others) to give us what stands today as the most enduring
description and categorization of schizophrenia.
1. He combined catatonia (alternating immobility and excited agitation), hebephrenia
(silly and immature emotionality), and paranoia (delusion of grandeur and
persecution), and include them under the Latin term dementia praecox.
2. He distinguished dementia praecox from bipolar disorder – for people with dementia
praecox, an early age of onset and a poor outcome were characteristic.

Eugen Bleuler, a Swiss psychiatrist introduced the term schizophrenia, which comes from
the Greek word “spilt” (skhizein) and “mind” (phren), reflected Bleuler’s belief that underlying
all the unusual behavior shown by people with this disorder was an associative splitting of
the basic functions of personality.

SOMATIC SYMPTOM AND RELATED DISORDERS

Hypochondriac is someone who exaggerates the slightest physical symptoms. For a few
individuals, the preoccupation with