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In the American Psychiatric Association's DSM-5, schizotypal personality disorder is defined as a "pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior, beginning by early adulthood and present in a variety of contexts."
At least five of the following symptoms must be present: ideas of reference, strange beliefs or magical thinking, abnormal perceptual experiences, strange thinking and speech, paranoia, inappropriate or constricted affect, strange behavior or appearance, lack of close friends, and excessive social anxiety that does not abate and stems from paranoia rather than negative judgments about self. These symptoms must not occur only during the course of a disorder with similar symptoms (such as schizophrenia or autism spectrum disorder).
Theodore Millon proposes two subtypes of schizotypal. Any individual with schizotypal personality disorder may exhibit either one of the following somewhat different subtypes "("Note that Millon believes it is rare for a personality with one pure variant, but rather a mixture of one major variant with one or more secondary variants):"
Depressive personality disorder (also known as melancholic personality disorder) is a controversial psychiatric diagnosis that denotes a personality disorder with depressive features.
Originally included in the American Psychiatric Association's DSM-II, depressive personality disorder was removed from the DSM-III and DSM-III-R. Recently, it has been reconsidered for reinstatement as a diagnosis. Depressive personality disorder is currently described in Appendix B in the DSM-IV-TR as worthy of further study. Although no longer listed as a personality disorder, the diagnosis is included under the section “personality disorder not otherwise specified”.
While depressive personality disorder shares some similarities with mood disorders such as dysthymia, it also shares many similarities with personality disorders including avoidant personality disorder. Some researchers argue that depressive personality disorder is sufficiently distinct from these other conditions so as to warrant a separate diagnosis.
The DSM-IV defines depressive personality disorder as "a pervasive pattern of depressive cognitions and behaviors beginning by early adulthood and occurring in a variety of contexts." Depressive personality disorder occurs before, during, and after major depressive episodes, making it a distinct diagnosis not included in the definition of either major depressive episodes or dysthymic disorder. Specifically, five or more of the following must be present most days for at least two years in order for a diagnosis of depressive personality disorder to be made:
- Usual mood is dominated by dejection, gloominess, cheerlessness, joylessness and unhappiness
- Self-concept centres on beliefs of inadequacy, worthlessness and low self-esteem
- Is critical, blaming and derogatory towards the self
- Is brooding and given to worry
- Is negativistic, critical and judgmental toward others
- Is pessimistic
- Is prone to feeling guilty or remorseful
People with depressive personality disorder have a generally gloomy outlook on life, themselves, the past and the future. They are plagued by issues developing and maintaining relationships. In addition, studies have found that people with depressive personality disorder are more likely to seek psychotherapy than people with Axis I depression spectrums diagnoses.
Recent studies have concluded that people with depressive personality disorder are at a greater risk of developing dysthymic disorder than a comparable group of people without depressive personality disorder. These findings lead to the fact that depressive personality disorder is a potential precursor to dysthymia or other depression spectrum diagnoses. If included in the DSM-V, depressive personality disorder would be included as a warning sign for potential development of more severe depressive episodes.
Researchers at McLean Hospital in Massachusetts looked at the comorbidity of depressive personality disorder and a variety of other disorders. It was found that subjects with depressive personality disorder were more likely than the subjects without depressive personality disorder to currently have major depression and an eating disorder. Subjects with and without depressive personality disorder were statistically equally likely to have any of the other disorders examined.
Bipolar disorder is difficult to diagnose. If a person displays some symptoms of bipolar disorder but not others, the clinician may diagnose bipolar NOS. The diagnosis of bipolar NOS is indicated when there is a rapid change (days) between manic and depressive symptoms and can also include recurring episodes of hypomania. Bipolar NOS may be diagnosed when it is difficult to tell whether bipolar is the primary disorder due to another general medical condition, such as a substance use disorder.
A spectrum disorder is a mental disorder that includes a range of linked conditions, sometimes also extending to include singular symptoms and traits. The different elements of a spectrum either have a similar appearance or are thought to be caused by the same underlying mechanism. In either case, a spectrum approach is taken because there appears to be "not a unitary disorder but rather a syndrome composed of subgroups". The spectrum may represent a range of severity, comprising relatively "severe" mental disorders through to relatively "mild and nonclinical deficits".
In some cases, a spectrum approach joins together conditions that were previously considered separately. A notable example of this trend is the autism spectrum, where conditions on this spectrum may now all be referred to as autism spectrum disorders. In other cases, what was treated as a single disorder comes to be seen (or seen once again) as comprising a range of types, a notable example being the bipolar spectrum. A spectrum approach may also expand the type or the severity of issues which are included, which may lessen the gap with other diagnoses or with what is considered "normal". Proponents of this approach argue that it is in line with evidence of gradations in the type or severity of symptoms in the general population, and helps reduce the stigma associated with a diagnosis. Critics, however, argue that it can take attention and resources away from the most serious conditions associated with the most disability, or on the other hand could unduly medicalize problems which are simply challenges people face in life.
These symptoms are not due to situations such as, person is depressed because of difficulty making friends. It is normal to experience dysfunctional emotions and behaviors at times.
Criteria are met for a neurotic or personality disorder, preferably at least two.
Some symptoms may include:
1. Depression.
2. Mania.
3. Anxiety.
4. Anger.
5. Dissociative symptoms such as depersonalization, derealization, deja vu, etc.
6. Emotional instability.
7. Psychopathic behavior.
8. Narcissism.
9. Paranoia.
10. Obsessive-compulsive behavior.
The current diagnostic criteria for MCDD are a matter of debate due to it not being in the DSM-IV or ICD-10. Various websites contain various diagnostic criteria. At least three of the following categories should be present. Co-occurring clusters of symptoms must also not be better explained by being symptoms of another disorder such as experiencing mood swings due to autism, cognitive difficulties due to schizophrenia, and so on. The exact diagnostic criteria for MCDD remain unclear but may be a useful diagnosis for people who do not fall into any specific category. It could also be argued that MCDD is a vague and unhelpful term for these patients.
BD-NOS is a mood disorder and one of three subtypes on the bipolar spectrum, which also includes bipolar I disorder and bipolar II disorder. BD-NOS was a classification in the DSM-IV and has since been changed to Bipolar "Other Specified" and "Unspecified" in the 2013 released DSM-5 (American Psychiatric Association, 2013).
The affective spectrum is a spectrum of affective disorders (mood disorders). It is a grouping of related psychiatric and medical disorders which may accompany bipolar, unipolar, and schizoaffective disorders at statistically higher rates than would normally be expected. These disorders are identified by a common positive response to the same types of pharmacologic treatments. They also aggregate strongly in families and may therefore share common heritable underlying physiologic anomalies.
Affective spectrum disorders include:
- Attention deficit hyperactivity disorder
- Bipolar disorder
- Body dysmorphic disorder
- Bulimia nervosa and other eating disorders
- Cataplexy
- Dysthymia
- Generalized anxiety disorder
- Hypersexuality
- Irritable bowel syndrome
- Impulse-control disorders
- Kleptomania
- Migraine
- Major depressive disorder
- Obsessive-compulsive disorder
- Oppositional defiant disorder
- Panic disorder
- Posttraumatic stress disorder
- Premenstrual dysphoric disorder
- Social anxiety disorder
- Fibromyalgia
The following may also be part of the spectrum accompanying affective disorders.
- Chronic pain
- Intermittent explosive disorder
- Pathological gambling
- Personality disorder
- Pyromania
- Substance abuse and addiction (includes alcoholism)
- Trichotillomania
Also, there are now studies linking heart disease.
Many of the terms above overlap. The American Psychiatric Association's definitions of these terms can be found in the "Diagnostic and Statistical Manual of Mental Disorders" (DSM).
A mood disorder (affective) spectrum or bipolar spectrum or depressive spectrum. These approaches have expanded out in different directions. On the one hand, work on major depressive disorder has identified a spectrum of subcategories and subthreshold symptoms which are prevalent, recurrent and associated with treatment needs. People are found to move between the subtypes and the main diagnostic type over time, suggesting a spectrum. This spectrum can include already recognised categories of minor depressive disorder, 'melancholic depression' and various kinds of atypical depression.
Going in another direction, numerous links and overlaps have been found between major depressive disorder and bipolar syndromes, including mixed states (simultaneous depression and mania or hypomania). Hypomanic ('below manic') and more rarely manic signs and symptoms have been found in a significant number of cases of major depressive disorder, suggesting not a categorical distinction but a dimension of frequency which is higher in bipolar II and higher again in bipolar I. In addition, numerous subtypes of bipolar have been proposed beyond the types already in the DSM (which includes a milder form called cyclothymia). These extra subgroups have been defined in terms of more detailed gradations of mood severity, or the rapidity of cycling, or the extent or nature of psychotic symptoms. Furthermore, due to shared characteristics between some types of Bipolar disorder and Borderline Personality Disorder, some researchers have suggested they may both lie on a spectrum of affective disorders, although others see more links to post-trauma syndromes.
Pathological demand avoidance (PDA) is a proposed subtype of autism characterized by an avoidance of demand-framed requests by an individual. It was proposed in 1980 by the UK child psychologist Elizabeth Newson. The Elizabeth Newson Centre in Nottingham, England carries out assessments for the NHS, local authorities and private patients around autism spectrum disorder, which include, but are not exclusively PDA.
PDA behaviours are consistent with autism, but have differences from other autism subtypes diagnoses. It is not recognised by either the DSM-5 or the .
A self-disorder, also called ipseity disturbance, is a psychological phenomenon of disruption or diminishing of a person's sense of minimal (or basic) self. The sense of minimal self refers to the very basic sense of having experiences that are one's own; it has no properties, unlike the more extended sense of self, the narrative self, which is characterized by the person's reflections on themselves as a person, things they like, their identity, and other aspects that are the result of reflection on one's self. Disturbances in the sense of minimal self, as measured by the Examination of Anomalous Self-Experience (EASE), aggregate in the schizophrenia spectrum disorders, to include schizotypal personality disorder, and distinguish them from other conditions such as psychotic bipolar disorder and borderline personality disorder.
Tourette’s syndrome is a neurological disorder characterized by recurrent involuntary movements (motor tics) and involuntary noises (vocal tics). The reason Tourette’s syndrome and other tic disorders are being considered for placement in the obsessive compulsive spectrum is because of the phenomenology and co-morbidity of the disorders with obsessive compulsive disorder. Within the population of patients with OCD up to 40% have a history of a tic disorder and 60% of people with Tourette’s syndrome have obsessions and/or compulsions. Plus 30% of people with Tourette’s syndrome have full-scale OCD. Course of illness is another factor that suggests correlation because it has been found that tics displayed in childhood are a predictor of obsessive and compulsive symptoms in late adolescence and early adulthood. However, the association of Tourette’s and tic disorders with OCD is challenged by neuropsychology and pharmaceutical treatment. Whereas OCD is treated with SSRI’s, tics are treated with dopamine blockers and alpha-2 agonists.
Whereas vanity involves a quest to aggrandize the appearance, BDD is experienced as a quest to merely normalize the appearance. Although delusional in about one of three cases, the appearance concern is usually nondelusional, an overvalued idea.
The bodily area of focus can be nearly any, yet is commonly face, hair, stomach, thighs, or hips. Some half dozen areas can be a roughly simultaneous focus. Many seek dermatological treatment or cosmetic surgery, which typically do not resolve the distress. On the other hand, attempts at self-treatment, as by skin picking, can create lesions where none previously existed.
BDD shares features with obsessive-compulsive disorder, but involves more depression and social avoidance. BDD often associates with social anxiety disorder. Some experience delusions that others are covertly pointing out their flaws. Cognitive testing and neuroimaging suggest both a bias toward detailed visual analysis and a tendency toward emotional hyperarousal.
Most generally, one experiencing BDD ruminates over the perceived bodily defect up to several hours daily, uses either social avoidance or camouflaging with cosmetics or apparel, repetitively checks the appearance, compares it to that of other persons, and might often seek verbal reassurances. One might sometimes avoid mirrors, repetitively change outfits, groom excessively, or restrict eating.
BDD's severity can wax and wane, and flareups tend to yield absences from school, work, or socializing, sometimes leading to protracted social isolation, with some becoming housebound for extended periods. Social impairment is usually greatest, sometimes approaching avoidance of all social activities. Poor concentration and motivation impair academic and occupational performance. The distress of BDD tends to exceed that of either major depressive disorder or type-2 diabetes, and rates of suicidal ideation and attempts are especially high.
It is common for individuals with PDD-NOS to have more intact social skills and a lower level of intellectual deficit than individuals with other PDDs. Characteristics of many individuals with PDD-NOS are:
- Communication difficulties (e.g., using and understanding language)
- Difficulty with social behavior
- Difficulty with changes in routines or environments
- Uneven skill development (strengths in some areas and delays in others)
- Unusual play with toys and other objects
- Repetitive body movements or behavior patterns
- Preoccupation with fantasy, such as imaginary friends in childhood
Mania is a distinct period of at least one week of elevated or irritable mood, which can range from euphoria to delirium, and those experiencing hypo- or mania may exhibit three or more of the following behaviors: speak in a rapid, uninterruptible manner, short attention span, racing thoughts, increased goal-oriented activities, agitation, or they may exhibit behaviors characterized as impulsive or high-risk, such as hypersexuality or excessive spending. To meet the definition for a manic episode, these behaviors must impair the individual's ability to socialize or work. If untreated, a manic episode usually lasts three to six months.
People with hypomania or mania may experience a decreased need of sleep, impaired judgment, and speak excessively and very rapidly. Manic individuals often have a history of substance abuse developed over years as a form of "self-medication". At the more extreme, a person in a full blown manic state can experience psychosis; a break with reality, a state in which thinking is affected along with mood. They may feel unstoppable, or as if they have been "chosen" and are on a "special mission", or have other grandiose or delusional ideas. This may lead to violent behavior and, sometimes, hospitalization in an inpatient psychiatric hospital. The severity of manic symptoms can be measured by rating scales such as the Young Mania Rating Scale, though questions remain about the reliability of these scales.
The onset of a manic or depressive episode is often foreshadowed by sleep disturbances. Mood changes, psychomotor and appetite changes, and an increase in anxiety can also occur up to three weeks before a manic episode develops.
Hypochondriasis is excessive preoccupancy or worry about having a serious illness. These thoughts cause a person a great deal of anxiety and stress. The prevalence of this disorder is the same for men and women. Hypochondriasis is normally recognized in early adult age. Those that suffer with hypochondriasis are constantly thinking of their body functions, minor bumps and bruises as well as body images. Hypochondriacs go to numerous outpatient facilities for confirmation of their own diagnosis. Hypochondriasis is the belief that something is wrong but it is not known to be a delusion.
Mania is the defining feature of bipolar disorder and can occur with different levels of severity. With milder levels of mania, known as hypomania, individuals are energetic, excitable, and may be highly productive. As hypomania worsens, individuals begin to exhibit erratic and impulsive behavior, often making poor decisions due to unrealistic ideas about the future, and sleep less. At the extreme, manic individuals can experience distorted or delusional beliefs about the universe, hallucinate, hear voices, to the point of psychosis. A depressive episode commonly follows an episode of mania. The biological mechanisms responsible for switching from a manic or hypomanic episode to a depressive episode, or vice versa, remain poorly understood.
Body dysmorphic disorder (BDD) is a mental disorder characterized by the obsessive idea that some aspect of one's own appearance is severely flawed and warrants exceptional measures to hide or fix it. In BDD's delusional variant, the flaw is imagined. If the flaw is actual, its importance is severely exaggerated. Either way, thoughts about it are pervasive and intrusive, occupying up to several hours a day. The "DSM-5" categorizes BDD in the obsessive–compulsive spectrum, and distinguishes it from anorexia nervosa.
BDD is estimated to affect up to 2.4% of the population. It usually starts during adolescence, and affects men and women roughly equally. The BDD subtype muscle dysmorphia, perceiving the body as too small, affects mostly males. Besides thinking about it, one repetitively checks and compares the perceived flaw, and can adopt unusual routines to avoid social contact that exposes it. Fearing the stigma of vanity, one usually hides the preoccupation. Commonly unsuspected even by psychiatrists, BDD has been underdiagnosed. Severely impairing quality of life via educational and occupational dysfunction and social isolation, BDD has high rates of suicidal thoughts and suicide attempts.
High-functioning autism (HFA) is a term applied to people with autism who are deemed to be cognitively "higher functioning" (with an IQ of 70 or greater) than other people with autism. Individuals with HFA or Asperger syndrome may exhibit deficits in areas of communication, emotion recognition and expression, and social interaction. HFA is not a recognized diagnosis in the DSM-5 or the ICD-10.
The amount of overlap between HFA and Asperger syndrome is disputed.
High-functioning autism is characterized by features very similar to those of Asperger syndrome. The defining characteristic most widely recognized by psychologists is a significant delay in the development of early speech and language skills, before the age of three years. The diagnostic criteria of Asperger syndrome exclude a general language delay.
Further differences in features between people with high-functioning autism and those with Asperger syndrome, include the following:
- People with HFA have a lower verbal reasoning ability
- Better visual/spatial skills (higher performance IQ) than people with Asperger syndrome
- Less deviating locomotion than people with Asperger syndrome
- People with HFA more often have problems functioning independently
- Curiosity and interest for many different things, in contrast to people with Asperger syndrome
- People with Asperger syndrome are better at empathizing with another
- The male to female ratio of 4:1 for HFA is much smaller than that of Asperger syndrome
Individuals with autism spectrum disorders, including high-functioning autism, risk developing symptoms of anxiety. While anxiety is one of the most commonly occurring mental health symptoms, children and adolescents with high functioning autism are at an even greater risk of developing symptoms.
There are other comorbidities, the presence of one or more disorders in addition to the primary disorder, associated with high-functioning autism. Some of these include depression, bipolar disorder, and obsessive compulsive disorder (OCD). In particular the link between HFA and OCD, has been studied; both have abnormalities associated with serotonin.
Observable comorbidities associated with HFA include ADHD, Tourette syndrome, and possibly criminal behavior. While the association between HFA and criminal behavior is not completely characterized, several studies have shown that the features associated with HFA may increase the probability of engaging in criminal behavior. While there is still a great deal of research that needs to be done in this area, recent studies on the correlation between HFA and criminal actions suggest that there is a need to understand the attributes of HFA that may lead to violent behavior. There have been several case studies that link the lack of empathy and social naïveté associated with HFA to criminal actions.
HFA does not cause nor include intellectual disabilities. This characteristic distinguishes HFA from the rest of the autism spectrum; between 40 and 55% of individuals with autism also have an intellectual disability.
Tics should be distinguished from other causes of tourettism, stereotypies, chorea, dyskinesias, myoclonus, and obsessive-compulsive disorder.
A pervasive developmental disorder not otherwise specified (PDD-NOS) is one of the four autism spectrum disorders (ASD) and also one of the five disorders classified as a pervasive developmental disorder (PDD). According to the DSM-IV, PDD-NOS is a diagnosis that is used for "severe and pervasive impairment in the development of reciprocal social interaction or verbal and nonverbal communication skills, or when stereotyped behavior, interests, and activities are present, but the criteria are not met for a specific PDD" or for several other disorders. PDD-NOS is often called atypical autism, because the criteria for autistic disorder are not met, for instance because of late age of onset, atypical symptomatology, or subthreshold symptomatology, or all of these. Even though PDD-NOS is considered milder than typical autism, this is not always true. While some characteristics may be milder, others may be more severe.
Pathological Demand Avoidance is not recognised by the DSM-5 or ICD-10, the two main classification systems for mental disorder.
To be recognized a sufficient amount of consensus and clinical history needs to be present, and as a newly proposed condition PDA had not met the standard of evidence required at the time of recent revisions. In April 2014 the UK Minister of State for Care and Support Norman Lamb stated that the Department of Health, "In the course of the development of the National Institute for Health and Care Excellence (NICE) clinical guideline on the treatment of autism in children and young people (CG128), the developers looked at differential diagnoses for autism. In this, they did consider PDA, identifying it as a particular subgroup of autism that could also be described as oppositional defiant disorder (ODD). The guidance recommends that consideration should be given to differential diagnoses for autism (including ODD) and whether specific assessments are needed to help interpret the autism history and observations. However, due to the lack of evidence and the fact that the syndrome is not recognised within the DSM or ICD classifications, NICE was unable to develop specific recommendations on the assessment and treatment of PDA."
So the National Institute for Health and Care Excellence (which provides guidelines on best practice for UK clinicians) makes no mention of PDA in its guidelines for diagnosis of autism either in children or adults.