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A. DELIRIUM
A - Disturbance of consciousness (ie, reduced clarity of
awareness of the environment) with reduced ability to focus,
sustain, or shift attention.
B - A change in cognition (such as memory deficit,
disorientation, language disturbance) or the development of a
perceptual disturbance that is not better accounted for by a
preexisting, established, or evolving dementia.
C - The disturbance develops over a short period of time
(usually hours to days) and tends to fluctuate during the course
of the day.
D - There is evidence from the history, physical examination, or
laboratory findings that the disturbance is caused by the direct
physiological consequences of a general medical condition.
A-C: Same as above
D - There is evidence from the history, physical examination, or
laboratory findings of either (1) or (2):
a.] The symptoms of Criteria A and B developed during substance
intoxication
b.] Medication use is etiologically related to the disturbance
A-C: Same as above
D - There is evidence from the history, physical examination, or
laboratory findings that the symptoms of Criteria A and B
developed during, or shortly after, a withdrawal syndrome.
B. AMNESTIC DISORDERS
The development of memory impairment as manifested by
impairment in the ability to learn new information or the
inability to recall previously learned information.
The memory disturbance causes significant impairment in social
or occupational functioning and represents a significant decline
from a previous level of functioning.
The memory disturbance does not occur exclusively during the
course of a delirium or a dementia and persists beyond the usual
duration of substance intoxication or withdrawal.
There is evidence from the history, physical examination, or
laboratory findings that the memory disturbance is etiologically
related to persisting effects of substance use (eg, a drug of
abuse, a medication).
The development of memory impairment as manifested by
impairment in the ability to learn new information or the
inability to recall previously learned information.
The memory disturbance causes significant impairment in social
or occupational functioning and represents a significant decline
from a previous level of functioning.
The memory disturbance does not occur exclusively during the
course of a delirium or a dementia.
There is evidence from the history, physical examination, or
laboratory findings that the disturbance is the direct
physiological consequence of a general medical condition
(including physical trauma).
C. Substance-Related Disorders
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:
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tolerance
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withdrawal
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the substance is often taken in larger amounts or over a longer
period than was intended
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there is a persistent desire or unsuccessful efforts to cut down
or control substance use
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a great deal of time is spent in activities necessary to obtain
the substance, use the substance, or recover from its effects
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important social, occupational, or recreational activities are
given up or reduced because of substance use
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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
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 failure to fulfill
major role obligations at work, school, or home
(2) recurrent substance use in situations in which it is
physically hazardous
(3) recurrent substance-related legal problems
(4) continued substance use despite having persistent or
recurrent social or interpersonal problems caused or exacerbated
by the effects of the substance
The symptoms have never met the criteria for substance
dependence for this class of substance.
The development of a reversible substance-specific syndrome
due to recent ingestion of (or exposure to) a substance.
Clinically significant maladaptive behavioral or psychological
changes that are due to the effect of the substance on the
central nervous system.
The symptoms are not due to a general medical condition and are
not better accounted for by another mental disorder.
The development of a substance-specific syndrome due to the
cessation of (or reduction in) substance use that has been heavy
and prolonged.
The substance-specific syndrome causes clinically significant
distress or impairment in social, occupational, or other
important areas of functioning.
The symptoms are not due to a general medical condition and are
not better accounted for by another mental disorder.
D. Schizophrenia
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 (eg, frequent derailment or incoherence)
(4) grossly disorganized or cataatonic behavior
(5) negative symptoms: ie, 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.
Social/occupational
dysfunction: For a significant portion of
the time since the onset of the disturbance, one or more major
areas of functioning such as work, interpersonal relations or
self-care are markedly below the level achieved prior to the
onset (or when the onset is in childhood or adolescence, failure
to achieve expected level of interpersonal, academic or
occupational achievement).
Duration: Continuous 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 (ie, active-phase symptoms) and may include periods
of prodromal or residual symptoms. During these prodromal or
residual periods, the signs of the disturbance may be manifested
by only negative symptoms or two or more symptoms listed in
Criterion A present in an attenuated form (eg, odd beliefs,
unusual perceptual experiences).
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.
Substance/general medical condition
exclusion: The
disturbance is not due to the direct physiological effects of a
substance (eg, a drug of abuse, a medication) or a general
medical condition.
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).
Psychosis, in its narrow definition, is restricted to
delusions (false, fixed beliefs) or hallucinations in the
absence of insight into their pathologic nature.
Schizophrenia is one of the major forms of psychotic
disorder. The concept of schizophrenia as a diagnostic entity is
still evolving even though the criteria in use today have been
fairly stable for nearly a decade. The current concept of
schizophrenia has its origins in the pioneering clinical
observations of Emil Kraepelin and Eugen Bleuler.
Kraepelin's great contribution was to distinguish
manic-depressive illness (now called bipolar disorder) as a
remitting, noncognitively impairing, relatively late-onset
psychosis (usually occurring in the fourth decade of life or
later) with a usually good vocational and social outcome, from
an early-onset psychosis (usually occurring in the second or
third decade), which could affect cognition permanently and
usually led to poor outcome. This latter psychosis was labeled
dementia praecox, the direct precursor of schizophrenia.
Bleuler's major
contribution was to suggest schizophrenia as
a more appropriate name than dementia praecox because of his
observation that the outcome of this illness was neither
universally poor nor associated with severe dementia and to
suggest that splitting of thought and affect was the central
feature of the illness. Bleuler specifically identified four
components that described the essence of the syndrome: autism,
ambivalence, flat affect, and disturbance of volition.
Kurt Schneider contributed the concept of first-rank symptoms
(eg, thought diffusion, thought insertion voices arguing and
commenting) which he believed were pathognomonic of
schizophrenia. It is now known that the first-rank symptoms are
not specific for schizophrenia.
E. Other Psychotic Disorders:
1. SCHIZOPHRENIFORM DISORDER
Criteria A, D, and E of schizophrenia must be met.
An episode of the disorder (including prodromal, active, and
residual phases) lasts at least 1 month but less than 6 months.
When the diagnosis must be made without waiting for recovery, it
should be qualified as "provisional."
* Specify if:
(1) onset of prominent psychotic symptoms within 4 weeks of the
first noticeable change in usual behavior or functioning
(2) confusion or perplexity at the height of the psychotic
episode
(3) good premorbid social and occupational functioning
(4) absence of blunted or flat affect
2. SCHIZOAFFECTIVE DISORDER
An uninterrupted period of illness during which, at some
time, there is either a major depressive disorder, a manic
episode, or a mixed episode concurrent with symptoms that meet
Criterion A for schizophrenia.
Note: The major depressive episode must include Criterion A1:
depressed mood.
During the same period of illness, there have been delusions or
hallucinations for at least 2 weeks in the absence of prominent
mood symptoms.
Symptoms that meet criteria for a mood episode are present for a
substantial portion of the total duration of the active and
residual periods of the illness.
The disturbance is not due to the direct physiological effects
of a substance (eg, a drug of abuse, a medication) or a general
medical condition.
* Specify type:
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Bipolar type: if the disturbance includes a manic or a mixed
episode (or a manic or a mixed episode and major depressive
episodes)
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Depressive type: if the disturbance only includes major
depressive episodes
3. DELUSIONAL DISORDER
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Nonbizarre delusions (ie, involving situations that occur in
real life, such as being followed, poisoned, infected, loved at
a distance, or deceived by spouse or lover, or having a disease)
of at least 1 month's duration.
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Criterion A for schizophrenia has never been met.
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Note: Tactile and olfactory hallucinations may be present in
delusional disorder if they are related to the delusional theme.
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Apart from the impact of the delusion(s) or its ramifications,
functioning is not markedly impaired and behavior is not
obviously odd or bizarre.
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If mood episodes have occurred concurrently with delusions,
their total duration has been brief relative to the duration of
the delusional periods.
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The disturbance is not due to the direct physiological effects
of a substance (eg, a drug of abuse, a medication) or a general
medical condition.
* Specify type (the following types are assigned based on the
predominant delusional theme):
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Erotomanic type: delusions that another person, usually of
higher status, is in love with the individual
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Grandiose type: delusions of inflated worth, power, knowledge,
identity, or special relationship to a deity or famous person
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Jealous type: delusions that the individual's sexual partner is
unfaithful
Persecutory type: delusions that the person (or someone to whom
the person is close) is being malevolently treated in some way
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Somatic type: delusions that the person has some physical defect
or general medical condition
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Mixed type: delusions characteristic of more than one of the
above types but no one theme predominates
4. BRIEF PSYCHOTIC DISORDER
Presence of one or more of the following symptoms:
(1) delusions
(2) hallucinations
(3) disorganized speech (eg, frequent derailment or incoherence)
(4) grossly disorganized or catatonic behavior
Note: Do not include a symptom if it is
a culturally
sanctioned response pattern.
Duration of an episode of the disturbance is at least 1 day
but less than 1 month, with eventual full return to premorbid
level of functioning.
The disturbance is not better accounted for by a mood
disorder with psychotic features, schizoaffective disorder, or
schizophrenia and is not due to the direct physiological effects
of a substance (eg, a drug of abuse, a medication) or a general
medical condition.
* Specify if:
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With marked stressor(s) (brief reactive psychosis): if
symptoms occur shortly after and apparently in response to
events that, singly or together, would be markedly stressful to
almost anyone in similar circumstances in the person's culture
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Without marked
stressor(s): if psychotic symptoms do not
occur shortly after, or are not apparently in response to events
that, singly or together, would be markedly stressful to almost
anyone in similar circumstances in the person's culture.
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With postpartum onset: if onset within 4 weeks postpartum
5. SHARED PSYCHOTIC DISORDER - "folie à deux"
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A delusion develops in the context of a close relationship
with another person(s), who has an already-established delusion.
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The delusion is similar in content to that of the person who
already has the established delusion.
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The disturbance is not better accounted for by another
psychotic disorder (eg, schizophrenia) or a mood disorder with
psychotic features and is not due to the direct physiological
effects of a substance (eg, a drug of abuse, a medication) or a
general medical condition.
6. PSYCHOTIC DISORDER DUE TO A GENERAL MEDICAL CONDITION
& SUBSTANCE-INDUCED PSYCHOTIC DISORDER
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Prominent hallucinations or delusions.
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There is evidence from the history, physical examination, or
laboratory findings that the disturbance is the direct
physiological consequence of a general medical condition.
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The disturbance is not better accounted for by another mental
disorder.
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The disturbance does not occur exclusively during the course of
a delirium.
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Prominent hallucinations or delusions.
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Note: Do not include hallucinations if the person has insight
that they are substance induced.
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There is evidence from the history, physical examination, or
laboratory findings of either (1) or (2):
(1) the symptoms in Criterion A developed during, or within a
month of, substance intoxication or withdrawal
(2) medication use is etiologically related to the disturbance
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The disturbance is not better accounted for by a psychotic
disorder that is not substance induced.
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Evidence that the
symptoms are better accounted for by a psychotic disorder that
is not substance induced might include the following: the
symptoms precede the onset of the use (or medication use); the
symptoms persist for a substantial period of time (eg, about a
month) after the cessation of acute withdrawal or severe
intoxication, or are substantially in excess of what would be
expected given the duration of use; or there is other evidence
that suggests the existence of an independent non-substance-induced psychotic disorder (eg, a history of
recurrent non-substance- related episodes).
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The disturbance does not occur exclusively during the course of
delirium.
7. PSYCHOTIC DISORDER NOT OTHERWISE SPECIFIED
Certain psychotic states cannot be classified into one of the
foregoing categories of psychoses and are referred to as
psychotic disorder NOS.
This category includes
psychotic symptomatology (ie,
delusions, hallucinations, disorganized speech, grossly
disorganized or catatonic behavior) about which there is
inadequate information to make a specific diagnosis or about
which there is contradictory information, or disorders with
psychotic symptoms that do not meet the criteria for any
specific psychotic disorder.
Examples include:
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Postpartum psychosis that does not meet criteria for mood
disorder with psychotic features, brief psychotic disorder,
psychotic disorder due to a general disorder
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Psychotic symptoms that have lasted for less than 1 month but
that have not yet remitted, so that the criteria for brief
psychotic disorder are not met
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Persistent auditory hallucinations in the absence of any other
features
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Persistent nonbizarre delusions with periods of overlapping mood
episodes that have been present for a substantial portion of the
delusional disturbance.
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Situations in which the clinician has concluded that a psychotic
disorder is present, but is unable to determine whether it is
primary, due to a general medical condition, or substance
induced
8. OTHER SPECIFIED OR CULTURE-BOUND PSYCHOTIC DISORDERS
Several psychotic disorders have specific presentations or
are contained within certain demographic groups. These disorders
are widely recognized but are not accorded formal diagnostic
status in DSM-IV.
They comprise the following:
A. Capgras Syndrome (delusion of doubles): This disorder
represents a fixed belief that familiar persons have been
replaced by identical imposters
who behave identically to the original person.
B.
Lycanthropy: This is a delusion that the person is a
werewolf or other animal.
C. Frégoli's Phenomenon: In this delusion, a persecutor (who
usually is following the person) changes faces or makeup to
avoid detection.
D. Cotard's Syndrome (délire de
négation): A false
perception of having lost everything, including money, status,
strength, health, but also internal organs. This may be seen in schizophrenia or psychotic
depression and responds to treatment of the underlying
condition.
E. Autoscopic Psychosis: The main symptom is a visual
hallucination of a transparent phantom of one's own body.
F.
Koro: This disorder in males is characterized by a sudden
belief that the penis is shrinking and may disappear into the
abdomen. An associated feature
may be the belief that when this occurs, the person will die. A
similar condition may be seen in women with fears of the loss of
the genitals or breasts. Although this problem is seen more
commonly in Asia, presentations in Western countries occur
occasionally.
G. Amok: The amok syndrome consists of an abrupt onset of
unprovoked and uncontrolled rage in which the affected person
may run about savagely attacking and even killing people and animals in his or her way.
It is seen most often in Malayan natives but has been reported
in other cultures. In some circumstances, this problem is
observed in individuals with preexisting psychotic disorders.
H. Piblokto (Arctic
Hysteria): This disorder occurs among the
Eskimos and is characterized by a sudden onset of screaming,
crying and tearing off of
clothes. The affected person may then run or roll about in the
snow. It usually resolves rapidly and the person will usually
have no memory of the event.
I. Windigo
(Witigo): Specific North American Indian tribes,
including the Cree and Ojibwa, manifest this rare psychotic
state. People affected may believe that they are possessed by a demon or monster that murders and
eats human flesh. Trivial symptoms including hunger or nausea
may induce intense agitation because of a fear of transformation into the demon.
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