Category Archives: DSM IV-TR

Diagnostic Criteria For Posttraumatic Stress Disorder

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PTSD was recognized in the early 1970s and formalized in 1980, largely the result of work by and with US veterans of the war in Vietnam. Many people who think about these things consider this recognition to be a turning point in psychological diagnosis. In fact, one way of thinking about psychological diagnosis is that most of what we now call Mental Disorders are basically variants of PTSD–the ways that different people respond to different traumas. If the committee working on version V of the DSM were to humor us, they might rename the tome The North American and European Catalog of Post-Traumatic Stress Behavior Patterns Plus a Few Other Human Difficulties.

Here’s a fuzzy map from the wikipedia article, showing PTSD rates. The darker the red, the more PTSD, and the lighter the yellow, the less:

Here are the criteria, word for word, from the Diagnostic and Statistical Manual of Mental Disorders IV-TR, pages 467 and 468:

Diagnostic criteria for 309.81 Posttraumatic Stress Disorder

A. The person has been exposed to a traumatic event in which both of the following were present:

(1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others

(2) the person’s response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior

B. The traumatic event is persistently reexperienced in one (or more) of the following ways:

(1) recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed.

(2) recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content.

(3) acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur.

(4) intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

(5) physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or More ) of the following:

(1) efforts to avoid thoughts, feelings, or conversations associated with the trauma

(2) efforts to avoid activities, places, or people that arouse recollections of the trauma

(3) inability to recall an important aspect of the trauma

(4) markedly diminished interest or participation in significant activities

(5) feeling of detachment or estrangement from others

(6) restricted range of affect (e.g., unable to have loving feelings)

(7) sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)

D. Persistent symptoms of increased arousal (not present before trauma), as indicated by two (or more) of the following:

(1) difficulty falling or staying asleep

(2) irritability or outbursts of anger

(3) difficulty concentrating

(4) hypervigilance

(5) exaggerated startle response

E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month.

F. The distrubance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify if:

Acute: if duration of symptoms is less than 3 months

Chronic: if duration of symptoms is 3 months or more

Specify if:

With Delayed Onset: if onset of symptoms is at least 6 months after the stressor

(First published May 16, 2011 on Nathen’s Miraculous Escape.)

DSM-IV-TR Diagnostic Criteria for Asperger’s Disorder

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There is quite a bit of controversy about it, but it looks as if Asperger’s Disorder will only be around for a couple more years. This diagnosis will probably get the axe in the upcoming DSM-V, when it arrives, subsumed into the so-called Autism Spectrum. It will be interesting to watch how a change in language will change how we think about a certain constellation of behaviors. If you’re interested, I have a link here to the proposed changes to the DSM.

Please read my disclaimer here about diagnosing yourself or anyone you know. The short version is, you can’t do it.

And, for the time being, here are the diagnostic criteria, word-for-word from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, page 84. As with Autistic Disorder, note the absence of qualities we may think of as common in Asperger’s Disorder, such as being picky about food or other things, being sensitive to things like noise or texture, any visual processing abnormalities such as non-susceptibility to visual illusion, being easily upset, self-harming behaviors, high IQ or “splinter skills.” None of these are considered in the diagnosis.

Diagnostic criteria for 299.80 Asperger’s Disorder

A. Qualitative impairment in social interaction, as manifested by at least two of the following:

(1) marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction

(2) failure to develop peer relationships appropriate to developmental level

(3) a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest to other people)

(4) lack of social or emotional reciprocity

B. Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following:

(1) encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus

(2) apparently inflexible adherence to specific, nonfunctional routines or rituals

(3) stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements)

(4) persistent preoccupation with parts of objects

C. The disturbance causes clinically significant impairment in social, occupational, or other important areas of functioning.

D. There is no clinically significant general delay in language (e.g., single words used by age 2 years, communicative phrases used by age 3 years).

E. There is no clinically significant delay in cognitive development or in the development of age-appropriate self-help skill, adaptive behavior (other than in social interaction), and curiosity about the environment in childhood.

F. Criteria are not met for another specific Pervasive Developmental Disorder or Schizophrenia.

[First published on Nathen’s Miraculous Escape, April 6, 2011.]

DSM-IV-TR Diagnostic Criteria for Autistic Disorder

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Please remember that I post diagnostic criteria here because it is interesting to know what kinds of behaviors can get you what kinds of diagnoses, not so you can diagnose yourself, anyone in your family, or any of your friends. You just cannot be objective enough and it often leads to people walking around thinking they have Mental Disorders that they do not have. This is especially not good if that person is a child.

This may be especially true for Autism-Spectrum Disorders, which require a team of experts collaborating with the family to make a good diagnosis, including ideally a developmental pediatrician, a psychologist, a social worker, a speech language specialist, an occupational therapist, and a physical therapist. Also maybe a family advocate and an early interventionist.  And that’s just for a medical diagnosis. It varies by state, but often educational eligibility requires, additionally, a school psychologist, a behavior specialist, and an autism specialist.

Notice in the criteria below that diagnosis is made based on social problems, language problems, and repetitive/stereotyped behaviors. Other qualities that we may associate with Autism, such as pickiness about food or other things, sensitivity to noise or textures, visual processing problems, being easily upset, self-harming behaviors, and “splinter skills” are not part of a diagnosis for Autistic Disorder. Even with extreme versions of those qualities, you do not an AD diagnosis without fitting the criteria below.

And here are the criteria, word for word from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (p. 75):

Diagnostic criteria for 299.00 Autistic Disorder

A. A total of six (or more) items from (1), (2), and (3), with at least two from (1), and one each from (2) and (3):

(1) qualitative impairment in social interaction, as manifested by at least two of the following:

(a) marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction.

(b) failure to develop peer relationships appropriate to developmental level

(c) a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest)

(d) lack of social or emotional reciprocity

(2) qualitative impairments in communication as manifested by at least one of the following:

(a) delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime)

(b) in individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others

(c) stereotyped and repetitive use of language or idiosyncratic language

(d) lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level

(3) restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following:

(a) encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus

(b) apparently inflexible adherence to specific, nonfunctional routines or rituals

(c) stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements)

(d) persistent preoccupation with parts of objects

B. Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3 years: (1) social interaction, (2) language as used in social communication, or (3) symbolic or imaginative play.

C. The disturbance is not better accounted for by Rett’s Disorder or Childhood Disintegrative Disorder.

[First published on Nathen’s Miraculous Escape, April 4, 2011.]

Akira, Swimming, and the Power of “You’re Weird”

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I go swimming most Friday evenings with my six-year-old friend, Akira. We started about a year and a half ago, calling it “swimming lessons.” Now we just call it “swimming.” It has been a joy to watch him learn to swim, just the way I think people should learn to swim: Having fun in the water, discovering new skills and games at whatever pace feels right. It took him almost exactly a year before he actually swam. He had slowly gotten comfortable putting his face in the water of the hot tub, and then found that when he did, he could lift his feet off of the bottom and float, which he started doing for 15-20 seconds at a time. Then one night he just started swimming, face down, slowly and relaxed, all the way across the hot tub. When he came up for a breath he was so excited. “Nathen! I don’t even have to swim! The water holds me up and all I have to do is pretend to swim!”

He is swimming three times a week now, and looks like a real natural–complete comfort in the water. You would never guess how nervous and circumspect he had been about water. He wouldn’t even blow bubbles for eight months–the bubbles popped uncomfortably close to his nose and eyes.

I am also getting to watch him grow up, which is mostly delightful. He is getting confident and funny–not surprising, since his parents are two of the funniest people I know.

Tonight, we were in the hot tub with another kid Akira’s age, and that kid started trying to make friends. “What’s your name?” “Can you do this?” Stuff like that. He seemed like a nice, friendly kid, and Akira was playing along. At a certain point the kid made an awkward move, standing too close and smiling too much. I realized later that he was going to try to lift Akira up out of the water a little, like he had seen me do. It created this awkward moment, though, and Akira said, “Weird.” The kid’s smile turned a little anxious, but he didn’t move away. Akira said “You’re weird. Get away from me.” The kid followed through with the lifting-up move, but instead of the original, playful feel, it ended up feeling aggressive, like, “This is what you get for calling me weird.”

I had an impulse to intervene, to stop the misunderstanding somehow. I had thought of this kid as a potential friend for Akira. I just didn’t think of anything to say besides, “Stop!” or “Don’t be mean.” Neither of those seemed right. The kid’s dad was there too, watching, and he didn’t say anything either. Akira started staying close to me, making a game of walking over my lap. I realized that he was nervous, that when he had said, “You’re weird,” he had been uncomfortable, a little scared.

Then it hit me what a powerful tool “You’re weird” is to a kid. Weird is the worst thing you can be at that age, the doorway to isolation and bullying. Being able to say “You’re weird” with enough poise shows where you stand in the hierarchy and rallies the troops of conformity to your aid. It is also a way to avoid vulnerability: A year ago, Akira would have just retreated, outwardly scared and confused. He would have whispered in my ear, “Can we go to the cold pool now?” Saying “you’re weird” was standing up for himself, a six-year old’s way of saying, “The way you are standing close to me is making me uncomfortable. Please stop doing that.”

So partly I was proud of him, and partly I was sad about the struggle he is entering into. It takes constant vigilance. Don’t be the weird one, the one who cries, the one who stands too close, the outcast, the one you can safely tease. Then, a few years later, don’t be the uncool one, the awkward one, the kid who gets beat up with impunity. Then, a few years later, don’t be the unhip one, who doesn’t quite know the right music in time, who has to pay close attention to stay on the tail-end of trends, the wannabe. For God’s sake, don’t let yourself be vulnerable! Every action must shout invulnerable and in control. And inside it’s, “Please believe me. He is the weird one. Not me. Him.”

I think conformity is a stage, unavoidable unless you are truly incapable of achieving it. I think it has to be negotiated by the kids, between the kids, for the most part. When Akira told me, “That kid is weird,” I said, “Well, I think he just wants to be friends,” but I couldn’t tell if it sunk in. And I don’t know how useful it would be if it did. Maybe the sooner he masters conformity, the sooner he can reject it and start exploring the joys and pain of vulnerability again.

[First published on Nathen’s Miraculous Escape, February 26, 2011.]

Diagnostic Criteria for Sleep Terror Disorder

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We don’t really know but the DSM estimates between 1 and 6% of children and many fewer adults have this experience. You are more likely to have this happen if you are related to someone who has had this happen, but we have no idea why. It usually just goes away in adolescence. If my parents had been the type to take their kids to mental health professionals, I almost certainly would have gotten this diagnosis as a kid. If so, and if my parents had been the drug-giving kind, I might have been prescribed a benzodiazepine (like Valium) for it. Generally, though, it can be treated by comforting your child when they wake up like this, until it goes away. If you think there might have been a triggering event for the condition, therapy might be helpful.

Here are the criteria, quoted word-for-word from the Diagnostic and Statistical Manual of Mental Disorders IV-TR, page 639:

Diagnostic criteria for 307.46 Sleep Terror Disorder

A. Recurrent episodes of abrupt awakening from sleep, usually occurring during the first third of the major sleep episode and beginning with a panicky scream.

B. Intense fear and signs of autonomic arousal, such as tachycardia, rapid breathing, and sweating, during each episode.

C. Relative unresponsiveness to efforts of others to comfort the person during the episode.

D. No detailed dream is recalled and there is amnesia for the episode.

E. The episodes cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

F. The disturbance is not due to  the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

[First published on Nathen’s Miraculous Escape, January 29, 2011.]

Diagnostic Criteria for Substance Abuse and Dependence

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I’m taking a class called Contemporary Issues in Addiction. One of the things we’re learning about is how different clinicians think about addiction. Here are the official diagnostic criteria for substance abuse and dependence, word-for-word from the DSM-IV-TR:

Criteria for Substance Abuse

A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:

(1) recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household)

(2) recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)

(3) recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct)

(4) continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights)

B. The symptoms have never met the criteria for Substance Dependence for this class of substance.

Criteria for Substance Dependence

A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:

(1) tolerance, as defined by either of the following:

(a) a need for markedly increased amounts of the substance to achieve intoxication or desired effect

(b) markedly diminished effect with continued use of the same amount of the substance

(2) withdrawal, as manifested by either of the following:

(a) the characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for Withdrawal from the specific substances)

(b) the same (or a closely related substance is taken to relieve or avoid withdrawal symptoms

(3) the substance is often taken in larger amounts or over a longer period than was intended

(4) there is a persistent desire or unsuccessful efforts to cut down or control substance use

(5) a great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain-smoking), or recover from its effects

(6) important social, occupational, or recreational activities are given up or reduced because of substance use

(7) the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption)

Specify if:

With Physiological Dependence: evidence of tolerance of withdrawal (i.e., either Item 1 or 2 is present)

Without Physiological Dependence: no evidence of tolerance or withdrawal (i.e., neither Item 1 nor 2 is present)

Course specifiers (see text [below] for definitions)

Early Full Remission

Early Partial Remission

Sustained Full Remission

Sustained Partial Remission

On Agonist Therapy

In a Controlled Environment

Here are those definitions, from pp. 196-7:

Early Full Remission. This specifier is used it, for at least 1 month, but for less than 12 months, no criteria for Dependence or Abuse have been met.

Early Partial Remission. This specifier is used it, for at least 1 month, but less than 12 months, one or more criteria for Dependence or Abuse have been met (but the full criteria for Dependence have not been met).

Sustained Full Remission. This specifier is used if none of the criteria for Dependence of Abuse have been met at any time during a period of 12 months or longer.

Sustained Partial Remission. This specifier is used if full criteria for Dependence have not been met for a period of 12 months or longer; however, one or more criteria for Dependence or Abuse have been met.

On Agonist Therapy. This specifier is used if the individual is on a prescribed agonist medication such as methadone and no criteria for Dependence or Abuse have been met for that class of medication for at least the past month (except tolerance to, or withdrawal from, the agonist). This category also applies to those being treated for Dependence using a partial agonist or an agonist/antagonist.

In a Controlled Environment. This specifier is used if the individual is in an environment where access to alcohol and controlled substances is restricted, and no criteria for Dependence or Abuse have been met for at least the past month. Examples of these environments are closely supervised and substance-free jails, therapeutic communities, or locked hospital units.

[Post first published on Nathen’s Miraculous Escape, October 4, 2010.]

Diagnostic Criteria for Gender Identity Disorder

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The existence of Gender Identity Disorder as an official mental disorder is troubling to the trans folks I know. They think of their condition they way most people now think about homosexuality: It’s just another normal way to be a human being that makes people who don’t understand it so afraid that they’ve called it a disorder. Some people are just born into bodies that don’t match their psychological gender.

There are other problems. There is the DSM’s requirement to specify whether the diagnosed individual is attracted to males, females, both, or neither. If homosexuality is not a mental disorder, why should it matter clinically what genders a transsexual is attracted to? Then there’s the fact that GID is in the DSM right next to the sexual disorders like sexual sadism, masochism, and pedophilia. What is the connection?

So in a way, it would be great to get GID removed from the DSM, like homosexuality was in the 1970s. Unfortunately, if GID were not an official mental disorder, insurance companies wouldn’t pay for the expensive surgeries and hormone treatments involved in transitioning. According to my friends, living in a body of the wrong sex is so painful and humiliating that many pre-operation trans folks kill themselves, while suicide is rare for those who do who get the operations. So if you are poor and trans, your life may depend on GID being an official mental disorder.

There may be some changes coming to the diagnosis (see here) in the upcoming DSM-V, and my friends are saying they sound somewhat better. Here’s how they stand right now, in theDiagnostic and Statistical Manual of Mental Disorders IV-TR:

Diagnostic criteria for Gender Identity Disorder

A. A strong and persistent cross-gender identification (not merely a desire for any perceived cultural advantages of being the other sex).

In children, the disturbance is manifested by four (or more) of the following:

(1) repeatedly stated desire to be, or insistence that he or she is, the other sex

(2) in boys, preference for cross-dressing or simulating female attire; in girls, insistence on wearing only stereotypical masculine clothing

(3) strong and persistent preferences for cross-sex roles in make-believe play or persistent fantasies of being the other sex

(4) intense desire to participate in the stereotypical games and pastimes of the other sex

(5) strong preference for playmates of the other sex

In adolescents and adults, the disturbance is manifested by symptoms such as a stated desire to be the other sex, frequent passing as the other sex, desire to live or be treated as the other sex, or the conviction that he or she has the typical feelings and reactions of the other sex.

B. Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex.

In children, the disturbance is manifested by any of the following: in boys, assertion that his penis or testes are disgusting or will disappear or assertion that it would be better not to have a penis, or aversion toward rough-and-tumble play and rejection of male  stereotypical toys, haves, and activities; in girls, rejection of urinating in a sitting position, assertion that she has or will grow a penis, or assertion that she does not want to grow breasts or menstruate, or marked aversion toward normative feminine clothing.

In adolescents and adults, the disturbance is manifested by symptoms such as preoccupation with getting rid of primary and secondary sex characteristics (e.g., request for hormones, surgery, or other procedures to physically alter sexual characteristics to simulate the other sex) or belief that he or she was born the wrong sex.

C. The disturbance is not concurrent with a physical intersex condition.

D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Code based on current age:

302.6     Gender Identity Disorder in Children

302.85   Gender Identity Disorder in Adolescents or Adults

Specify if (for sexually mature individuals):

Sexually Attracted to Males

Sexually Attracted to Females

Sexually Attracted to Both

Sexually Attracted to Neither

[First posted on Nathen’s Miraculous Escape, August 22, 2010.]

Diagnostic Criteria for Schizophrenia

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Schizophrenia is a fascinating set of phenomena, the study of which has launched a thousand ships including, arguably, my field, family therapy; many of the original family therapists left psychiatry to study schizophrenia (or, as the DSM would have me write it, Schizophrenia–capitalizing words gives them more authority, don’t you think?) as an interactive process. That is, if all behaviors make sense in their context, what context might make schizophrenic behavior necessary?

There was an almost violent backlash against this line of thinking, as it seemed to (and did, in many cases) blame mothers for their schizophrenic children–as in the unfortunate phrase “schizophrenogenic mother.” The conventional wisdom about schizophrenia these days reads like a pharmaceutical company press release, something like, “Schizophrenia is a biological disease of the brain which is at present incurable, but there are drugs which can help manage the symptoms, and if taken regularly can provide a decent quality of life.”

So schizophrenia is assumed to be a biological disease of the brain though it, like every other Mental Disorder, has no laboratory test that can detect its presence. The best we can do is a set of behavioral diagnostic criteria which, frankly, are a bit of a mess. You may notice as you read that different flavors of schizophrenia may have nothing or little in common with each other. Are they really the same “disease”? We don’t know.

We do have good evidence that you can inherit, in some fashion, a tendency for one of these constellations of behaviors. There is good evidence that environmental factors are also important, though they are not a big part of the mainstream discussion. We also have evidence that therapy helps in a lot of cases. There is some (hotly contested, I’m sure) evidence from the World Health Organization that unmedicated schizophrenics can eventually recover while those on medication do not. Here is a trailer for a moving documentary about two recovered women and the public perception of schizophrenia, called Take These Broken Wings. Also, consider checking out the documentary A Brilliant Madness, about John Nash, in which puts the lie to A Brilliant Mind, which showed Nash recovering with the help of psychopharmaceuticals.

The DSM says that schizophrenia may be overdiagnosed (or at least is diagnosed more often) in African- and Asian-American men, that it affects men differently than women (men tend towards the negative symptoms were women tend towards delusions and hallucinations), and that incidence rates are something like .5-1.5% of adults.

Here are a few terms that you’ll need to know to get through the criteria:

affective flattening: does not show emotion. Also, “affect” means “emotion” to scientists and people who like to talk like scientists.

alogia: lack of speech.

avolition: lack of motivation.

prodromal: symptoms coming early on in the course of a disease.

echolalia: repetition of others’ speech sounds.

echopraxia: repetition of others’ movements

And here are the diagnostic criteria, word-for-word, from the DSM-IV-TR, pp. 312-319:

Diagnostic criteria for Schizophrenia

A. Characteristic symptoms: Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated):

(1) delusions

(2) hallucinations

(3) disorganized speech (e.g. frequent derailment or incoherence)

(4) grossly disorganized or catatonic behavior

(5) negative symptoms, i.e., affective flattening, alogia, or avolition

Note: Only one Criterion A symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person’s behavior or thoughts, or two or more voices conversing with each other.

B. Social/occupational dysfunction: For a significatn portion of the time since th onset of the distrubance, one or more major areas of functioning such as work, interpersonal relations, or self-care are mardekly below the level achieved prior to the onset (or when the onset is in childhood or adolewscence, faliure to achieve expected level of interpersonal, academic, or occupational achievement).

C. Duration: Continuou signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. Doring these prodromal or residual periods, the signs of the ditrubance may be manifested by only negative symptoms or two or more symptoms listen in Criterion A pressent in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).

D. Schizoaffective and Mood Disorder exclusion: Schizoaffective Disorder and Mood Disorder With Psychotic Features have been ruled out because either (1) no Major Depressive, Manic, or Mixed Episodes have occurred concurrently with the active-phase symptoms; or (2) if mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods.

E. Substance/general medical condition exclusion: The disturbance is not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or a general medical condition.

F. Relationship to a Pervasive Developmental Disorder: If there is a history of Autistic Disorder or another Pervasive Developmental Disorder, the additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month (or less if successfully treated).

Classification of longitudinal course (can be applied only after at least 1 year has elapsed since the initial onset of active-phase symptoms):

Episodic With Interepisode Residual Symptoms (episodes are difined by the reemergence of prominent psychotic symptoms); also specify if: With Prominent Negative Symptoms

Episodic With No Interepisode Residual Symptoms

Continuous (prominent psychotic symptoms are present throughout the period of observation); also specify if: With Prominent Negative Symptoms

Single Episode In Partial Remission; also specify if: With Prominent Negative Symptoms

Single Episode In Full Remission

Other or Unspecified Pattern

Diagnostic criteria for 295.30 Paranoid Type

A type of Schizophrenia in which the following criteria are met:

A. Preoccupation with one or more delusions or frequent auditory hallucinations.

B. None of the following is prominent: disorganized speech, disorganized or catatonic behavior, or flat or inappropriate affect.

Diagnostic criteria for 295.10 Disorganized Type

A type of Schizophrenia in which the following criteria are met:

A. All of the following are prominent:

(1) disorganized speech

(2) disorganized behavior

(3) flat or inappropriate affect

B. The criteria are not met for Catatonic Type.

Diagnostic criteria for 295.20 Catatonic Type

A type of Schizophrenia in which the clinical picture is dominated by at least two of the following:

(1) motoric immobility as evidenced by catalepsy (including waxy flexibility) or stupor

(2) excessive motor activity (that is apparently purposeless and not influenced by external stimuli

(3) extreme negativism (an apparently motiveless resistance to all instructions or maintenance of a rigid posture against attempts to be moved) or mutism

(4) peculiarities of voluntary movement as evidenced by posturing (voluntary assumptions of inappropriate or bizarre postures), stereotyped movements, prominent mannerisms, or prominent grimacing

(5) echolalia or echopraxia

Diagnostic criteria for 295.90 Undifferentiated Type

A type of Schizophrenia in which symptoms that meet Criterion A are present, but the criteria are not met for the Paranoid, Disorganized, or Catatonic Type.

Diagnostic criteria for 295.60 Residual Type

A type of Schizophrenia in which the following criteria are met:

A. Absence of prominent delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior.

B. There is continuing evidence of the disturbance, as indicated by the presence of negative symptoms or two or more symptoms listed in Criterion A for Schizophrenia, present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).

[First published on Nathen’s Miraculous Escape, May 31, 2010.]

Diagnostic Criteria for Sexual Sadism and Masochism

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I was surprised that these criteria did not specifically mention pain. I had thought that sadism and masochism were about wanting to hurt and be hurt. Reading these makes me think that it’s more about issues around control and humiliation than enjoying the sensation of pain.

This is word-for-word from the DSM-IV-TR, pages 573 and 574:

Diagnostic criteria for 302.84 Sexual Sadism

A. Over a period of at least 6 months, recurrent, intense, sexually arousing fantasies, sexual urges, or behaviors involving acts (real, not simulated) in which the psychological or physical suffering (including humiliation) of the victim is sexually exciting to the person.

B. The person has acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies cause marked distress or interpersonal difficulty.

Diagnostic criteria for 302.83 Sexual Masochism

A. Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving the act (real, not simulated) of being humiliated, beaten, bound, or otherwise made to suffer.

B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or important areas of functioning.

[First posted on Nathen’s Miraculous Escape, May 30, 2010.]

Oppositional Defiant Disorder Assessment Handout

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[First published on Nathen’s Miraculous Escape]

The most useful assessment tool is the DSM-IV-TR Diagnostic Criteria:

A. A pattern of negativistic, hostile, and defiant behavior lasting at least 6 months, during which four (or more) of the following are present:

(1) often loses temper

(2) often argues with adults

(3) often actively defies or refuses to comply with adults’ requests or rules

(4) often deliberately annoys people

(5) often blames others for his or her mistakes or misbehavior

(6) is often touchy or easily annoyed by others

(7) is often angry or resentful

(8) is often spiteful or vindictive

Note: Consider a criterion met only if the behavior occurs more frequently than is typically observed in individuals of comparable age and developmental level.

B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.

C. The behaviors do not occur exclusively during the course of a Psychotic or Mood Disorder.D. Criteria are not met for Conduct Disorder, and, if the individual is age 18 or older, criteria are not met for Antisocial Personality Disorder.

 

There are also several assessment tools, which have varying degrees of consistency with clinical-interview-derived diagnoses, test-retest reliability, and source-variance problems. They also cost a lot. What you basically need to know about them is that using these rating scales, teacher and parent opinions about ODD barely agree, and if their agreement was necessary, ODD would be about .2% of the population, down from up to 16%, according to the DSM. Parents’ opinions tend to be more closely related to clinicians’ and are probably more accurate. Note that the DSM does not require ODD to be present in more than one context, but consider your stance on this. If teacher says ODD and parents say no ODD, or vice versa, will you make the diagnosis?

Here are a list of common assessment tools, so that you can recognize them: Diagnostic Interview Schedule for Children, Child Behavior Checklist, Behavior Assessment System for Children: Second Edition, Disruptive Behavior Disorders Structured Parent Interview, Burke’s Behavioral Rating Scale, IOWA Conners Teacher Rating Scale, Disruptive Behavior Rating Scale, Oppositional Defiant Disorder Rating Scale, SNAP-IV Teacher and Parent Rating Scale. I did a fair bit of research on the use of these systems for ODD. If you’re interested, see my summary here.

Considerations for making a systemic diagnosis: I have my doubts that this diagnosis can be made in good faith by a system thinker; it pathologizes an individual child for a condition that is very likely contextual in nature. However, it is medicated less than many of its alternatives, such as ADHD, CD, and RAD, and its treatment goals are inherently relational, so a case can be made to use this diagnosis to funnel resources to families in need. In making a systemic diagnosis, remember that ODD is correlated with disrupted attachment, parenting that is authoritative, neglectful, or abusive, parental psychopathology (especially maternal depression), and marital discord.

Some books which might be helpful: Books for Parents: Your Defiant Child, Russell A. Barkley, PhD, Guilford Press, 1998; The Explosive Child, Ross Greene, PhD, Harper Paperbacks, 2001; Raising Your Spirited Child, Mary Sheedy Kurcinka, Harper Paperbacks, 1998; The Angry Child, Timothy Murphy, PhD, Three Rivers Press, 2002; How to Behave So Your Child Will Too, Sal Severe, PhD, Penguin Books, 2003; It’s Nobody’s Fault, Harold Koplewicz, MD, Three Rivers Press, 1997; Books for Children: The Behavior Survival Guide for Kids, Thomas McIntyre, Free Spirit, 2003; How to Take the Grrrr Out of Anger, Elizabeth Verdick and Marjorie Lisovskis, Free Spirit, 2002; Josh’s Smiley Faces: A Story About Anger, Gina Ditta-Donahue, Magination Press, 2003; Learning to Listen, Learning to Care, Lawrence Shapiro, Instant Help Publications, 2004; Books for Professionals: What Works for Whom: A Critical Review of Psychotherapy Research, Anthony Ross and Peter Fonagy, Guilford Press, 2004; Helping Children with Aggression and Conduct Problems: Best Practices for Intervention, Michael Bloomquist and Steven V. Schnell, Guilford Press, 2005