All posts by Paul Susic

Trauma and Stressor-Related Disorders: DSM-V Diagnostic Codes




Trauma and Stressor-Related Disorders: New category

The trauma and stressor related disorders category is a new chapter in the DSM-V. This category now includes post traumatic stress disorder, acute stress disorder, reactive attachment disorder (RAD), adjustment disorders and the new diagnostic category, disinhibited social engagement disorder (DSED). In the previous DSM-IV-TR, acute stress disorder and posttraumatic stress disorder were included in the anxiety disorders category. These disorders are now included in the same diagnostic category in the DSM-V because of their common roots in external events.

Trauma and Stressor-Related Disorders: Overview

Besides being placed in the new category, a significant change includes the necessity for the stressor criterion for posttraumatic stress disorder and acute stress disorder to be met. The stressor or traumatic event can be either directly or indirectly experienced or witnessed by an individual receiving a diagnosis of either post traumatic stress disorder or acute stress disorder. The traumatic event can be experienced by a family member or friend, having a significant effect on the individual receiving the diagnosis.

The term trauma usually refers to a significant response to a very distressing experience such as a terrible accident, sexual assault, abuse, combat or exposure to natural or human disasters. Stressful events can be either emotionally or physically harmful or both and can involve either a single experience or repetitive events over a period of time. Traumatic events can affect different people in very different ways, but have the overall experience of threatening their physical, emotional or spiritual welfare. The trauma is always experienced as overwhelming the individual’s ability to cope.

Some of the more common traumatic events have included sexual and physical assault, robbery, combat, terrorist attacks being kidnapped and taken hostage, being tortured, disasters, child abuse, automobile accidents and life-threatening illnesses. Traumatic events may also include witnessing a person’s death or serious injury through violence, war, accidents or natural disasters.




Prevalence:

The prevalence rate of traumatic related disorders is very high among the general population in the United States. The lifetime prevalence rate among men is 3.6% with a rate of 9.7% among women. The rate among children does not seem to be currently available although it is recognized that children who have experienced traumatic events are also at very high risk of developing posttraumatic stress disorder. The prevalence rates of acute stress disorder are between 6% and 94% depending upon the type of stressor involved. It is estimated that approximately 1% of children under the age of five have some degree of reactive attachment disorder. Children who are placed in foster care or are orphaned are at a much higher risk of developing reactive attachment disorder. Adjustment disorders are estimated to be between 2% and 8% in community-based samples of children, adolescents and among the elderly.

Diagnosis:

The onset of traumatic stress related disorders also increases the risk of associated mental health disorders such as anxiety, depression, sleeping and eating disorders, problems with substance use and suicidal ideation. It is also common for individuals diagnosed with a traumatic or stress related disorder to also have symptoms of somatic symptom disorder and/or attention deficit hyperactivity disorder and impulse control disorders. Many children who survived traumatic events are also misdiagnosed as having attention deficit hyperactivity disorder. Children diagnosed with reactive attachment disorder are also frequently mistaken for children with attention deficit hyperactivity disorder or oppositional defiant disorder and frequently have behavioral problems during childhood and throughout their adolescent years.

Important information:

It is important for mental health counselors and clinicians to understand that with the new category of traumatic stress related disorders that the most fundamental feature is trauma rather than anxiety serving as the precipitant to the development of the disorder.
Specific information and treatment information related to each of the individual diagnosis within the category of trauma and stress related disorders follows on subsequent pages.

Trauma and Stressor-Related Disorders: DSM-V Diagnostic Codes

313.89 (F94.1) Reactive Attachment Disorder
Specify if: Persistent
Specify current severity: Severe

313.89 (F94.2) Disinhibited Social Engagement Disorder

Specify if: Persistent
Specify current severity: Severe

309.81 (F43.10) Posttraumatic Stress Disorder (includes Posttraumatic Stress Disorder for Children 6 Years and Younger)

Specify whether: With dissociative symptoms
Specify if: With delayed expression

308.3 (F43.0) Acute Stress Disorder

___.__ (___.__) Adjustment Disorders

Specify whether:
309.0 (F43.21) With depressed mood
309.24 (F43.22) With anxiety
309.28 (F43.23) With mixed anxiety and depressed mood
309.3 (F43.24) With disturbance of conduct
309.4 (F43.25) With mixed disturbance of emotions and conduct
309.9 (F43.20) Unspecified
309.89 (F43.8) Other Specified Trauma-and Stressor-Related Disorder
309.9 (F43.9) Unspecified Trauma-and Stressor-Related Disorder

Diagnostic Information and Criterion for Trauma and Stressor-Related Disorders adapted from the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition American Psychological Association by Paul Susic Ph.D. Licensed Psychologist



Schizophrenia Spectrum and Other Psychotic Disorders DSM-5 Diagnostic Codes:





Schizophrenia Spectrum and Other Psychotic Disorders DSM-5 Diagnostic Codes: Overview

Psychiatric diagnosis that fall within the category of schizophrenia spectrum and other psychotic disorders are characterized by abnormalities in one or more of the following five categories: hallucinations, delusions, disorganized thinking, disorganized or abnormal motor behavior (including catatonia) negative symptoms. This section includes information related to each of the specific schizophrenia spectrum and other psychotic disorders included in the DSM-5. These include delusional disorder, brief psychotic disorder, schizophreniform disorder, schizophrenia, schizoaffective disorder, substance/medication-induced psychotic disorder, psychotic disorder due to another medical condition and catatonia.

Psychotic disorders involve a variety of both positive and negative as well as some related cognitive symptoms. Positive symptoms involve thoughts and behaviors that you would not usually expect while negative symptoms involve the absence of expected experiences. Some of the basic positive symptoms include hallucinations and delusions, as well as thinking or movement disorders in which the individual seems to lose touch with reality. Hallucinations are sensory experiences such as visual and auditory hallucinations, olfactory hallucinations, gustatory hallucinations (tasting), or tactile or somatic hallucinations in which a person feels things that are not really there or do not seem to have an actual physical stimulus. Delusions are rigid beliefs that do not seem to have any basis in reality and from which an individual cannot be persuaded otherwise. Auditory hallucinations seem to be the most common and tactile hallucinations are frequently associated with withdrawal or intoxication from substances. Olfactory and gustatory hallucinations often indicate a possible underlying medical problem. Disorganized thoughts often referred to as thought disorder involves disruptions in thinking in such a way that communication becomes difficult. Disorganized or abnormal motor behavior frequently referred to as movement disorder, includes agitation, recurrent motions or an inability to respond or move in relation to specific stimuli such as with catatonia.

Negative symptoms within the schizophrenia spectrum category include a lack of motivation, pleasure or engagement in what are believed to be normal activities of daily living or the normal experiencing of emotion. Problems with cognitive symptoms are usually related to having a difficulty with executive functioning, memory or attention.

Schizophrenia Spectrum and Other Psychotic Disorders: Prevalence

According to the APA (2013) psychotic disorders are fairly uncommon, citing prevalence rates of disorders within the schizophrenia spectrum category to range from 0.2% to 0.7%. These do not account for any cross-cultural considerations that are not identified in the DSM-5 but seem to be commonly found in specific cultures throughout the world.




Individuals who experience psychotic disorders have various characteristics and experiences. For about 50% of the individuals diagnosed within this category, they experience a lifelong struggle of trying to maintain their symptoms and a modest level of functioning in their lives. A small minority of individuals who have a later age of onset and frequently a higher level of functioning, seem to be able to manage their symptoms more adequately over their lifetime.

The presence of positive symptoms of psychosis does not always indicate the presence of a psychotic disorder. Medical conditions and substance use and abuse can also lead to the onset and often the exacerbation of psychotic symptoms. In many or most cases, it is probably better for a mental health clinician to refer clients with psychotic symptoms for a thorough medical examination.

Cause and Treatment:

At the present time, researchers have not determined the cause of schizophrenia and other psychotic disorders. Medical conditions and substance use as well as other mental health conditions can lead or contribute to the severity of schizophrenia spectrum and other psychotic disorders. Studies have found a strong genetic connection among individuals with schizophrenia spectrum disorders and have identified various physiological conditions associated with psychosis. Individuals with first-degree relatives who have a condition within the schizophrenia spectrum may be as much as 10 times higher risk of developing the symptoms of psychotic disorders. Neuroscientific researchers have found that individuals with schizophrenic spectrum disorders have different brain structures and physiological components from those who do not.

The main focus of the treatment of schizophrenia and related disorders includes medications for the relief of symptoms and the management of relapse. Psychological interventions are used to promote coping, and for preventing relapse, providing assistance through supportive measures to attain the highest level of functioning in an individual’s activities of daily life.

The same treatment principles seem to apply to all disorders within the schizophrenic spectrum. In the acute phase, clinicians will try to manage the most acute symptoms through medication management and supportive services. Following the medication management of the acute symptoms, clinicians may then focus more on psychosocial treatments to reduce stress and assist the client and their families through psychoeducation and supportive services to maintain a relatively higher managed level of psychosis that allows them to function at the highest level possible in their lives. Finally, as they continue with their medications, clinicians can then attend to preventing relapse through psychological treatments which include skills training, psychoeducation, cognitive behavioral therapy, family interventions, supported employment and other psychological support services within the treatment community. Strong therapeutic relationships have been identified to be very important in assisting and promoting more positive attitudes and compliance with medications.

Please see below the specific schizophrenia spectrum and other psychotic disorders diagnostic codes as well as important diagnostic and treatment information.

Schizophrenia Spectrum and Other Psychotic Disorders DSM-5 Diagnostic Codes:

301.22 (F21) Schizotypal (Personality) Disorder

297.1 (F22) Delusional Disorder

Specify whether: Erotomanic type, Grandiose type, Jealous type, Persecutory type, Somatic type, Mixed type, Unspecified type

298.8 (F23) Brief Psychotic Disorder

Specify if: With marked stressor(s), Without marked stressor(s), With postpartum onset

295.40 (F20.81) Schizophreniform Disorder

Specify if: With good prognostic features, Without good prognostic features

295.90 (F20.9) Schizophrenia

___.__ (__.__} Schizoaffective Disorder
Specify whether:

295.70 (F25.0) Bipolar Type

295.70 (F25.1) Depressive Type

___.__ (__.__) Substance/Medication-Induced Psychotic Disorder

Note: See the criteria set and corresponding recording procedures for substance-specific codes and ICD-9-CM and ICD-10-CM coding.
Specify if: With onset during intoxication, With onset during withdrawal

___.__ (__.__) Psychotic Disorder Due to Another Medical Condition
Specify whether:

293.81 (F06.2) With Delusions

293.82 (F06.0) With Hallucinations

293.89 (F0 61) Catatonia Associated With Another Mental Disorder (Catatonia Specifier)

293.89 (F06.1) Catatonia Disorder Due to Another Medical Condition

293.89 (F06.1) Unspecified Catatonia
Note: Code first 781.99 (R29.818) other symptoms involving nervous and musculoskeletal systems.

298.8 (F28) Other Specified Schizophrenia Spectrum and Other Psychotic Disorder

298.9 (F29) Unspecified Schizophrenia Spectrum and Other Psychotic Disorder

Diagnostic Information and Criterion for Schizophrenia Spectrum and Other Psychotic Disorders adapted from the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition American Psychological Association by Paul Susic Ph.D. Licensed Psychologist


Obsessive-Compulsive and Related Disorders: DSM-5 Diagnostic Codes




Obsessive-Compulsive and Related Disorders: Introduction

Conditions which fall within the category of Obsessive-Compulsive and Related Disorders all share some key features of obsessions and compulsions. Obsessions are recurrent, persistent and intrusive anxiety provoking thoughts or images resulting in subsequent repetitive behaviors referred to as compulsions. Obsessions may include thoughts, feelings, ideas and sensations that compel a person to do specific behaviors or compulsions. Some of the more common obsessions include excessive counting, ruminating about physical flaws, hoarding and picking at one’s skin. Some of the resulting rituals which are common among individuals diagnosed with obsessive-compulsive disorder frequently include recurrent handwashing, frequently checking doors and locks and avoidance of specific situations. For an individual to be considered for a diagnosis of obsessive-compulsive disorder it must be disruptive to their daily existence and functioning. Disorders listed in this category all share the common feature of excessive preoccupation along with the subsequent engagement in repetitive behaviors.

Changes from the DSM-4 TR to the DSM-5:

There were significant changes from previous editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM). Obsessive-compulsive disorder was previously classified in the DSM-4 TR as an anxiety disorder. The new DSM-5 has created a standalone chapter separate from the other anxiety disorders. This also follows revisions within the ICD 10 CM which also classifies OCD separately from anxiety disorders. However, there should never be any confusion as to the close relationship between obsessive-compulsive disorders and anxiety disorders. When the separation of obsessive-compulsive disorder from anxiety disorders was anticipated prior to the publication of the new DSM-5, psychiatrists supported the move significantly more often than other mental health clinicians, with only 40% to 45% of other mental health professionals supporting the move to the new category. Many psychologists, counselors and other mental health professionals did not support the change because of the fact that most treatment protocols for obsessive-compulsive disorder are also similar for anxiety and other related disorders. As is the case with most anxiety related disorders and depression, comorbidity is frequently the rule rather than the exception.




Some of the new disorders that fall within this category include excoriation (skin picking) disorder, substance/medication -induced obsessive compulsive and related disorder, hoarding disorder and obsessive-compulsive and related disorder due to another medical condition. Also, the diagnosis of trichotillomania (hair pulling disorder) was moved from the DSM-4 TR classification of impulse control disorders to this new classification of Obsessive-Compulsive and Related Disorders in the DSM-5.

Diagnosis:

An important aspect of diagnosis is to differentiate obsessive-compulsive disorder from other mental health disorders by the key features of obsessive preoccupation and repetitive behaviors. Once this has been accomplished, diagnosis can proceed.

Diagnosis of obsessive-compulsive disorder can be challenging in that there is a high level of comorbidity with other diagnosis. It is very common for a person with this diagnosis to also exhibit

symptoms of anxiety disorders and depression; eating disorder; somatoform disorder; hypochondriasis; impulse-control disorder, especially kleptomania; and attention deficit hyperactivity disorder (ADHD). Also, there is a significant amount of literature considering the comorbidity between obsessive-compulsive disorder and Tourette’s syndrome.

Prevalence:

It has been estimated that as many as one in 100 or 2 to 3 million adults currently have obsessive-compulsive disorder. Among children it is estimated that nearly one in 200 or 500,000 children and adolescents may receive this diagnosis. These estimates do not include other related disorders. Hoarding is believed to affect about 4% of the general population. Trichotillomania may affect as many as 2.5 million Americans, and as many as 3.8% of college students are believed to exhibit symptoms of excoriation.

Treatment for Obsessive-Compulsive and Related Disorders:

The most commonly reported treatments include a combination of medication and psychological treatments. Some studies have found cognitive behavioral therapy to be more effective than treatment with drugs or often has been found to be an appropriate replacement after the initial symptoms have been reduced. The International Obsessive-Compulsive Disorder Foundation has recommended exposure and response prevention (ERP), which is a type of cognitive behavioral therapy and has concluded that this type of therapy may reduce the symptoms by as much as 60% to 80% for active participants in therapy.

General information on obsessive-compulsive disorder can be found on subsequent pages along with information specific to each diagnosis within the new DSM-5 category of Obsessive-Compulsive and Related Disorders.

Obsessive-Compulsive and Related Disorders DSM-5 Diagnostic Codes:

300.3 (F42) Obsessive-Compulsive Disorder
Specify if: Tic-related

300.7 (F45.22) Body Dysmorphic Disorder
Specify if: With muscle dysmorphia

300.3 (F42) Hoarding Disorder
Specify if: With excessive acquisition

312.39 (F63.2) Trichotillomania (hair pulling disorder)

698.4 (L96.1) Excoriation (skin picking) Disorder

294.8 (F06.8) Obsessive-Compulsive and Related Disorder Due to Another Medical Condition
Specify if: With obsessive-compulsive disorder-like symptoms, With appearance preoccupations, With hoarding symptoms, With hair pulling symptoms, With skin picking symptoms.

300.3 (F42) Other Specified Obsessive-Compulsive and Related Disorder

300.3 (F42) Unspecified Obsessive-Compulsive and Related Disorder

Diagnostic Information and Criterion for Obsessive-Compulsive and Related Disorders adapted from the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition American Psychological Association by Paul Susic Ph.D. Licensed Psychologist



The Mystery of Happiness: Paul Susic Ph.D.




When we reflect upon the tapestry of experiences and emotions that come to define the patterns of our lives, we continue to stumble our way toward that seemingly elusive state we refer to as happiness. What is happiness? How do we find it when it often seems to be just around the next meandering turn in our lives? How do we recognize it when we have it?




One of the best clues to true happiness may be found in a parable about the alley cat and the kitten told by psychologist Wayne Dyer Ph.D. I have paraphrased it in my own words below.

A wise old alley cat came upon a kitten who was doing what kittens do, with boundless energy was chasing its tail around, and around, and around. The alley cat asked the kitten; “Why are you chasing your tail?” The kitten replied: “I have discovered that happiness is in my tail, and I am trying to catch it.” The wise old cat thought for a second and replied to the kitten. “I too have found happiness to be in my tail, but I find that if I just go about my business it just follows right behind me.”

We look at the world around us and chase after the many things that we feel will bring us that seemingly elusive happiness that will last. We look to relationships with people, to new jobs, new homes, a car or even those life goals that only seem to make us happy for a while. We continue to look “out there” rather than “in there”. And we wonder why we seem to continue to find disappointment in place of the things that should bring happiness.

Maybe the alley cat was not only wiser than the kitten, but was actually smarter than many of us, in that happiness is about our focus. Maybe, happiness really never was an elusive mystery. Maybe, it was there with us all along.

By Paul Susic Ph.D. Licensed Psychologist


Schizoid Personality Disorder Symptoms and DSM-V Diagnosis




F60.1 (301.20) Schizoid Personality Disorder: Overview

Individuals with schizoid personality disorder are indifferent to social experiences and interpersonal relationships. There is usually a lifelong history of very restricted emotional expression and feeling, unsociability, reclusiveness and emotional coldness.

Persons with schizoid personality disorder have little interest in relationships, even family relationships. They usually prefer isolated experiences which rarely involve other people. They typically have few to no friends, take no pleasure in activities with others and most often have no interest in intimate relationships and sex with others. Emotional reactions to others are usually cold, elusive and they have difficulty experiencing emotions in general. Usually they are uninterested in and not responsive to the assessments of others or even to encouragement or criticism.




The symptoms of schizoid personality disorder cannot occur only during a psychotic episode such as with schizophrenia and cannot be attributed to antisocial personality disorder. The symptoms must significantly impair the individuals functioning to warrant a diagnosis of this personality disorder.

Although this disorder may affect as many as 3.1% of the population in the United States, these individuals will usually not seek treatment. The impairment in social and occupational functioning is very significant.

Treatment of Schizoid Personality Disorder

Treatment for this disorder may be conducted using cognitive behavioral therapy along with a psychodynamic theoretical perspective when conceptualized within the perspective of attachment theory. Several psychological theorists and clinicians have concluded that the role of the counselor may be crucial in that this individual seems to need a model for interpersonal relationships. Also, it is important to recognize that people with this disorder may experience brief psychotic episodes when experiencing significant levels of stress.

Additional Considerations: Schizoid Personality Disorder:

Schizoid personality disorder seems to occur more often among men than women. It is important for the therapist to consider the cultural context when working with and diagnosing individuals with schizoid personality disorder as some cultures seem to emphasize defensive behaviors and detachment more than others. Also, additional consideration needs to be given to individuals who have changed cultures such as immigrants who experience issues related to acculturation.

Differential Diagnosis of Schizoid Personality Disorder
:
When considering whether an individual has schizoid personality disorder, the clinician needs to be careful that the symptoms are not related to substance use, another medical condition such as those that affect the central nervous system and medication use. It is also important to understand that this diagnosis should not be given if the symptoms only occur within the context of psychosis.

F60.1 (301.20) Schizoid Personality Disorder Diagnostic Criteria:

A. A pervasive pattern of detachment from social relationships and a very restricted range of expression of emotions in interpersonal experiences, usually beginning in early adulthood and manifested in a variety of contexts, as well as indicated by four or more of the following symptoms:

1. Neither enjoys nor desires close interpersonal relationships, including being part of a family experience.
2. Almost always chooses solitary activities.
3. Has little to no interest in having sexual relationships with others.
4. Takes pleasure in a very limited number of activities.
5. Has no close friends or confidants besides first-degree relatives.
6. Is indifferent to the praise or criticism of others.
7. Seems cold emotionally, detached or has a very flattened affect.

B. The symptoms do not occur exclusively during the course of schizophrenia, bipolar disorder or a depressive disorder with psychotic features, another psychotic disorder, an autism spectrum disorder and is not attributable to the physiological effects of another medical condition

Note: If the above symptoms and criteria are met prior to the onset of schizophrenia, add “premorbid” such as “schizoid personality disorder (premorbid).”

Adapted from the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-V) American Psychiatric Association by Paul Susic Ph.D. Licensed Psychologist


Alzheimer’s Disease: What is its cause and prevelance?




Alzheimer’s Disease: Prevalence and Cause

Alzheimer’s Disease Prevalence

Alzheimer’s disease is the most prevalent cause of dementia, accounting for between 55% 65% of all cases of dementia. While there were fewer than 3 million cases of Alzheimer’s disease diagnosed in the United States in 1980, the Census Bureau predicts there will be more than 10 million American citizens with Alzheimer’s disease by the year 2050. The prevalence of this disease is believed to double with every five year period of time between the ages of 65 and 85 years old.




Some researchers separate Alzheimer’s disease into senile and pre-senile forms, although the two disorders actually represent the same pathological process. However, the early-onset type (onset before the age of 65) of Alzheimer’s disease is usually associated with a more rapid course of progression than the later-onset type.

Alzheimer’s disease affects women at a rate of 3 to 1 over men (although the reasons are unknown). Also, at least one study has suggested dementia, including Alzheimer’s disease, is more common in black then white American women. Interestingly enough, comparison of population studies in various countries show distinctly similar prevalence rates.

Alzheimer’s Disease Cause:

The cause and pathogenesis of Alzheimer’s disease is unknown. It is believed that multiple causative pathways are likely involved in this disorder. There have been many hypothesis regarding the cause and progression of Alzheimer’s disease including genetic factors, slow or unconventional viruses, defective membrane metabolism, endogenous toxins, autoimmune disorders, and neurotoxicity of such trace elements as aluminum and mercury.

It is known that the brains of individuals with Alzheimer’s disease contain senile plaques, neurofibrillary tangles and Hirano’s bodies. There is a deterioration of nerve cells, but the atrophy seen on neural diagnostic examination may be more the result shrinkage of neurons and the loss of dendritic spines then of the actual neuronal loss. Certain parts of the brain, such as the association cortex demonstrate the most apparent changes, with early decay in the primary motor and sensory areas being relatively spared from these changes. Cholinergic abnormalities are exhibited in the neurochemicals of the brain. There is a significant decrease in acetylcholine in most individuals along with decreased immunological activity of somatostatin and corticotropin-releasing factors. The enzyme required for acetylcholine synthesis, choline acetyltransferase, is also significantly reduced. Other studies seem to suggest involvement of the noradrenergic and serotonergic systems in later-onset Alzheimer’s disease and reduced gamma-aminobutyric acid (GABA). Although it is a well-known fact that the involvement of cholinergic transmission along the hippocampus and nucleus basalis essential to the ability to learn new information, it is believed that many of the symptoms of Alzheimer’s disease are not totally explained on the basis of cholinergic abnormalities. Investigators continue to examine a variety of other potential causative or contributing factors.

Researchers have also investigated the role of beta-amyloid protein in Alzheimer’s disease, and some even believe that this material, a significant component of all plaques, is a major contributor to the neurodegenerative changes associated with the disease, possibly both initiating and promoting the disease process. This assertion is also supported by genetic studies of families with heritable forms of presenile dementia, which seem to indicate that disease occurrence is linked to mutations involving beta-amyloid-related systems. Also, some investigators have focused on the neurofibrillary tangles and the identification of a major component of its helical filament, the tau protein. These researchers have considered the possibility that modification of tau protein, predominantly by phosphorylation, is an important feature in the development of Alzheimer’s disease.

By Paul Susic Ph.D. Licensed Psychologist


Personality Disorders Symptoms and DSM-V Diagnosis




Personality Disorders Symptoms and Diagnosis: An overview

Personality disorders symptoms are not always easy to distinguish from relatively normal behaviors, although the consequences can be tremendously different. Personality disorders are groups of traits and characteristics that have become very rigid and dysfunctional, severely limiting functioning and most often resulting in severe distress and impairment. These thinking and behavioral patterns have usually been identified in these individual for a long time and in most cases since late adolescence or early adulthood.

The characteristics associated with personality disorders should probably be considered dimensional rather than categorical in that they are also seen in normal individuals to a significantly lesser degree. The DSM-V however has continued the traditional structure of categories that has been used over the last 30 years.

Common Characteristics of the Personality Disorders:

In order to receive a diagnosis of a personality disorder there needs to be an enduring pattern of negative behaviors, thoughts, feelings and sensations that are substantially different from the individual’s culture. This pattern includes an individual’s affect, cognition, control of impulses, and interpersonal relationships. This pattern of behaving and thinking has to apply in a broad-based manner over the individual’s personal and social life.




Personality disorders usually begin in adolescence (sometimes childhood) or early adulthood and manifest themselves in many social and personal contexts and cause a high level of distress and disability in an individual’s working and educational experience, as well as social and personal functioning. These characteristics cannot be associated with substance abuse, other mental disorders, physical illness, other personality disorders or personality changes associated with other medical conditions. The hallmark of personality disorders is their level of early onset (most commonly late teens), intensity of characteristics and pervasive nature in that it affects multiple aspects of an individual’s life including work, personal and social life.

A couple of the problems associated with the recognition and diagnosis of personality disorders is that they are frequently overlooked and at other times may be over-diagnosed. Two of the more notorious over diagnosed personality disorders are probably the narcissistic and borderline personality disorders. In DSM-V Made Easy, James Morrissey identified several things for a clinician keep in mind when making a diagnosis of personality disorder.

1. Verify the duration of the symptoms. Make sure that your patient’s symptoms have been present at least since early adulthood (before age 15 for antisocial personality disorder).
2. Verify that the symptoms affect several areas of the patient’s life.
3. Make sure that the patient fully qualifies for the particular diagnosis in question.
4. If the patient is under age 18, make sure that the symptoms have been present for at least the past 12 months.
5. Rule out other mental pathology that may be more accurate and have greater potential for doing harm.
6. Search for other personality disorders. Evaluate the entire history to learn whether any additional personality disorders are present.
7. Record all personality and non-personality mental diagnosis.

The following are the most commonly diagnosed personality disorders:


Cluster A Personality Disorders:

The Cluster A personality disorders usually involve behaviors described as suspicious, cold, withdrawn and/or irrational.

F60.0 (301.0) Paranoid Personality Disorder
F60.1 (301.20) Schizoid Personality Disorder
F21 (301.22) Schizotypal Personality Disorder

Cluster B Personality Disorders:

People who experience Cluster B Personality Disorders usually tend to be dramatic, very emotional and attention seeking with shallow, fluctuating moods. They often have intense interpersonal problems.

F60.2 (301.7) Antisocial Personality Disorder
F60,3 (301.83) Borderline Personality Disorder
F60.4 (301.50) Histrionic Personality Disorder
F60.81 (301.81) Narcissistic Personality Disorder

Cluster C Personality Disorders:

The Cluster C Personality Disorders usually feature characteristics of being typically tense, anxious and being over controlled.

F60.6 (301.82) Avoidant Personality Disorder
F60.7 (301.6) Dependent Personality Disorder
F60.5 (301.4) Obsessive-Compulsive Personality Disorder

Other Personality Conditions:

F07.0 (301.1) Personality Change Due to Another Medical Condition
F60.89 (301.89) Other Specified Personality Disorder
F60.9 (301.9) Unspecified Personality Disorder

By Paul Susic Ph.D. Licensed Psychologist



Paranoid Personality Disorder Symptoms and DSM-V Criteria




301.0 (F 60.0) Paranoid Personality Disorder: Overview

The key features of paranoid personality disorder involve suspicion of others and mistrust in their motivations. This disorder begins in early adulthood and persists for life and may affect multiple areas of functioning in their daily experience. The signs of mistrust must be manifested in at least four areas of their life including an inability to trust or rely upon friends and difficulty confiding in others because of fear that what is shared will be used against them, constant suspicion that others are trying to harm, trick or exploit them. They may have a pervasive pattern of not forgiving others and may misperceive insults and threats in normal conversation. They often believe that others are trying to assault their character. They obviously then feel a need to respond to the attack and frequently have a chronic suspicion that their spouse or partner is unfaithful to them.





Additional Aspects of Paranoid Personality Disorder:

This personality disorder occurs more often in men than women and is estimated to affect about 4.4% of the population in the United States. The sentiment and perspective of individuals with this disorder should not be confused with the feelings of oppression or disenfranchisement experienced by some minority, immigrant and refugee groups in the United States of America. Individuals who experience or have a family history of psychotic disorders such as schizophrenia or have other unique experiences such as being incarcerated are more often diagnosed with paranoid personality disorder.

Diagnosing Paranoid Personality Disorder:

As mentioned above, it is very important not to confuse the symptoms of psychotic disorders such as schizophrenia with paranoid personality disorder. This diagnosis would be given if the symptoms of paranoid personality disorder also persist before and after the psychotic symptoms of schizophrenia. It is important to understand that there is a significant overlap or comorbidity among personality disorders. Psychologists, psychiatrists and other mental health clinicians need to screen for whether another personality disorder may be even more appropriate such as schizotypal personality disorder.

301.0 (F 60.0) Paranoid Personality Disorder Diagnostic Criteria

A. Suspiciousness and pervasive mistrust of others in their motivations that are interpreted as malevolent, which began in early adulthood and is manifested in a variety of contexts as indicated by four (or more) of the following:

1. Suspects without a sufficient basis that others are harming, exploiting or deceiving them.
2. Has a preoccupation without justification about the trustworthiness or loyalty of friends, family or associates.
3. A reluctance to confide in others because of an unwarranted fear that the information will be used negatively against them.
4. Reads threatening meanings and demeaning motivations behind benign remarks or events.
5. Unforgiving of other’s insults, slights and perceived injuries and persistently bearing grudges
6. Perceives attacks on their character and reputation that is not apparent to others and reacts quickly and angrily in counterattack.
7. Has recurrent suspicions although unjustified about the fidelity of their spouse or sexual partner.

B. The symptoms do not occur exclusively during the course of schizophrenia, bipolar disorder or depressive disorder with psychotic features, or other psychotic disorders that are not attributable to the physiological effects of another medical condition.

Note: If the criteria are met before the onset of schizophrenia, add “premorbid,” such as “paranoid personality disorder (premorbid).”

Adapted from the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) American Psychiatric Association By Paul Susic Ph.D. Licensed Psychologist


Unnecessary Medication Use Associated With Dementia Diagnosis




Introduction to the study:

A recent study conducted at the University of Sydney has found that inappropriate and unnecessary medications seem to be routinely prescribed for newly diagnosed dementia patients. This longitudinal research study of 2,500 people was conducted in collaboration with the University of Kentucky and Yale University and published in the Journals of Gerontology: Medical Sciences.

Estimates of people currently living with dementia is approximately 50 million worldwide. In Australia the estimate is approximately 425,000 costing the country more than $15 billion per year and is currently the second leading cause of death.




Study and Conclusions:

The lead author, Dr. Danijela Gnjidic, NHMRC Dementia Leadership Fellow and Senior Lecturer from the Faculty of Pharmacy and Charles Perkins Centre at University of Sydney stated that “Our study found that following a diagnosis of dementia in older people, medication use increased by 11 per cent in a year and the use of potentially inappropriate medications increased by 17 percent”. She went on to say, “These medications are typically recommended for short term use but are commonly used long term by people with dementia,”

Some of the more common unnecessary and inappropriate medications are pain pills, sleep aids, depression medications and drugs for acid reflux referred to as proton pump inhibitors

A number of reasons were given to account for this including a lack of time in the patient and physician encounters, inappropriate guidelines, difficulty in setting goals with the patient and difficulty in the communication and comprehension of the patient.
She stated, “These findings are of major concern and highlight the importance of weighing up the harms and benefits of taking potentially unnecessary medications as they may lead to increased risk of side effects such as sedation or drowsiness, and adverse drug events such as falls, fractures and hospitalization.” She felt that increased efforts need to be made to support the recognition and potential use of medications that are inappropriate to minimize harm to patients.
Finally, Dr. Gnjidic concluded that “For Australians living with dementia and their caregivers (who commonly are responsible for managing medications for people with dementia), the key is to communicate closely with general practitioners, pharmacists and other health professionals to make informed decisions and to practice good medicine management techniques to minimize the risk of side effects.” Also, she commented that “Deprescribing unnecessary medications may improve an individual’s quality of life and can reduce unnecessary healthcare cost.”

Adapted by Paul Susic Ph.D. Licensed Psychologist from article at ScienceDaily: Dementia Diagnosis Linked to Unnecessary Medication Use dated Apr. 19, 2018

Story Source:

Materials provided by University of Sydney. Note: Content may be edited for style and length.

Journal Reference:

Danijela Gnjidic, George O Agogo, Christine M Ramsey, Daniela C Moga, Heather Allore. The impact of dementia diagnosis on patterns of potentially inappropriate medication use among older adults. The Journals of Gerontology: Series A, 2018; DOI: 10.1093/gerona/gly078



Generalized Anxiety Disorder: What is it exactly?




Generalized Anxiety Disorder: An Overview

Generalized anxiety disorder is a form of anxiety that is chronic, lasts for at least six months and is not accompanied by obsessions, phobias or panic attacks. A person with generalized anxiety disorder experiences constant worry and anxiety without all the comorbid symptoms of other anxiety disorders. To be given a diagnosis of this anxiety disorder, you must be focused on two or more specific, stressful life experiences such as significant concern related to work, finances, relationships or other issues most days for a minimum of six months. Individuals with generalized anxiety disorder often spend a lot of time worrying and tend to have several or many significant concerns. However, it is very difficult to manage any control over your worries and anxiety when you have this disorder. Also, the worries tend to be significantly out of proportion to the actual threat involved.




If you have generalized anxiety disorder, you will most often have at least three of the following six symptoms, most days for a minimum of six months:

• Irritability
• difficulty concentrating
• difficulties with sleep
• being fatigued easily
• feeling restless
• tension in the muscles

Another important aspect of generalized anxiety disorder is that you will experience a significant level of distress and impairment in daily activities related to work, school and social experiences.

Most often, before a physician will diagnose you as having this anxiety disorder he/she will have ruled out most possible medical causes of chronic anxiety such as thyroid problems, drug-induced anxiety and hyperventilation. Generalized anxiety disorder also often occurs at the same time as depression. A competent psychologist or mental health clinician will quickly try to distinguish whether the anxiety should be treated as the primary or secondary disorder. It is often difficult to tell which came first.

This anxiety disorder can develop at any age. Among children and adolescents, the focus of worries will tend to be related to school or performance in sports. The source of concern among adults can be related to a variety of circumstances. It is believed that generalized anxiety disorder affects approximately 4% of the population in the United States and may be slightly more common among women (55% to 60%) than men.

Generalized anxiety disorder is not usually associated with any specific phobias. However, Aaron Beck M.D., has suggested that the disorder may be related to some “basic fears” of a broad-based nature. They may include:

• fear of being unable to cope
• fear of failure
• fear of disease and death
• fear of abandonment or rejection
• fear of losing control

Generalized anxiety disorder may be exacerbated by any circumstance that increases your perception of danger or seems threatening. The underlying cause is unknown although it is believed to be related to some combination of heredity and experiences in childhood such as excessive expectations of parents, fears of abandonment or rejection by others.

Treatment for Generalized Anxiety Disorder:

Cognitive Behavioral Therapy

Often some form of cognitive behavioral therapy is used to treat generalized anxiety disorder. Utilizing this type of psychotherapy involves identifying themes of worry and fearful self-talk which is then challenged and replaced by more positive, constructive thoughts. More realistic, positive thoughts are used to replace counterproductive thoughts which are then practiced and internalized over time. Cognitive behavioral therapy may also utilize guided imagery to replace negative with more positive themes of mental imagery.

Medication

Medications may be recommended for generalized anxiety disorder in moderate to severe cases. These medications may involve the use of both anxiety medications and antidepressants. Frequently, the anxiety medication Buspar may be used. At other times SSRI antidepressants may be used such as Luvox, Zoloft, Paxil or Serzone either alone or in conjunction with| Buspar.

Relaxation Training

Relaxation training for generalized anxiety disorder usually involves some type of deep breathing and relaxation techniques to reduce the generalized worry and feeling of anxiety. Also, a consistent exercise program may also be included.

Problem-solving

Problem-solving usually takes the form of systematically working through and solving issues in our lives that seem to be a focus of worries. The focus becomes on solutions as opposed to the worries themselves. If there is no practical solution to a problem, the focus then becomes on ways to cope with the situation rather than continuing to worry about it. Sometimes, we may need to learn to accept things that we cannot change.

Distraction

Distraction can also be used at times to help cope with worries that are not amenable to treatment with cognitive behavioral therapy or problem-solving. Distraction may involve diverting your attention to other activities such as listening to music, talking on the telephone, exercising, cooking, reading or solving puzzles.

Personality and Lifestyle Changes

Intervention along these lines tend to focus on the use of methods usually described to assist with panic disorder such as increased downtime, stress management, regular exercise, and eliminating stimulants and sweets from your diet. It may also involve resolving problems with others, changing attitudes toward perfectionism, a need to please others or an excessive need to feel in control.

By Paul Susic Ph.D. Licensed Psychologist