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Martin Freeman
Matthew Henshaw
John Horner
Sara Odze
(DSM-IV-TR #293.00)

The hallmark of delirium is confusion, or, as it also has been called, clouding of the sensorium. Patients may appear somewhat dazed and unclear about their surroundings. They have difficulty perceiving correctly what goes on around them, and one may have difficulty capturing and holding their attention—they tend to drift off. Short-term memory is poor, and patients tend to lose grasp of what happened only minutes before; disorientation to time and place are common accompanying features.

Delusions and illusions or hallucinations may occur. Cracks in the ceiling may seem to be alive and moving; the ringing of a telephone is a fire alarm. Hallucinations tend to be visual: the family is gathered about the bed; animals burrow under the blankets; an angel hovers outside the window. They may hear sounds or muffled whispers; a voice may announce the patient’s death or impending execution. Delusions tend to be of the persecutory type and are rarely systematized. The syringe is filled with poison; the hospital is an elaborate prison; the physicians wish only to experiment on the patient.

The patient’s speech may be circumstantial, tangential, or incoherent. Though not universal, a classic sign is carphologia, wherein the patient repetitively and aimlessly picks at the sheets or bed clothes. Sleep reversal may occur.

Upon formal mental status testing, in addition to confusion, one finds a degree of disorientation to time and/or place, an inability to recall all of three words after 5 minutes, and a decreased attention span, as measured by testing the digit span.

The overall behavior of the delirious patient may tend either toward agitation or quietude. Patients with an overactive or “noisy” delirium may be unable to stay in bed; they may climb over the bed rails, pull out intravenous lines and attempt to escape out the window. Those with delusions of persecution may refuse all care and even may attack those who try to take care of them. Frightening hallucinations may leave the patient terrified and screaming.

On the other hand, patients with a “quiet” or underactive delirium may not draw any clinical attention at all. They may lie listless and uncomplaining and do whatever they are told. All the while, however, they may have no sense of what is going on around them or why they are where they are.

Typically, though not universally, the symptoms of delirium tend to fluctuate over time. “Sundowning” is often seen as the patient’s confusion worsens with the coming of night. In some cases, especially in the morning, patients may display a “lucid interval” wherein they appear quite clear and alert. Such morning lucid intervals may mislead diagnosticians as they make morning rounds.

Upon recovery from the delirium, patients have at best a patchy recall for the experience.

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Jeremy Dziedzic
Chris Reeg
(DSM-IV-TR #307.52)

The essential feature of Pica is the eating of one or more non-nutritive substances on a persistent basis for a period of at least 1 month (Criterion A).

The typical substances ingested tend to vary with age. Infants and younger children typically eat paint, plaster, string, hair, or cloth. Older children may eat animal droppings, sand, insects, leaves, or pebbles. Adolescents and adults may consume clay or soil. There is no aversion to food. This behavior must be developmentally inappropriate (Criterion B) and not part of a culturally sanctioned practice (Criterion C).

The eating of non-nutritive substances is an associated feature of other mental disorders (e.g., Pervasive Developmental Disorder, Mental Retardation). If the eating behavior occurs exclusively during the course of another mental disorder, a separate diagnosis of Pica should be made only if the eating behavior is sufficiently severe to warrant independent clinical attention (Criterion D).

Pica is frequently associated with Mental Retardation and Pervasive Developmental Disorders. Although vitamin or mineral deficiencies (e.g., zinc) have been reported in some instances, usually no specific biological abnormalities are found. In some cases, Pica comes to clinical attention only following general medical complications (e.g., lead poisoning as a result of ingesting paint or paint-soaked plaster, mechanical bowel problems, intestinal obstruction as a result of hair ball tumors, intestinal perforation, or infections such as toxoplasmosis and toxocariasis as a result of ingesting feces or dirt).

Poverty, neglect, lack of parental supervision, and developmental delay increase the risk for the condition....

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Ed Downey
Eric Frate
Martin Freeman
R. Scott Oliver
(DSM-IV-TR #300.30)

Obsessive-compulsive disorder, once known as “obsessive- compulsive neurosis,” and occasionally referred to by subtype designations, such as “délire de doute” or “délire de toucher,” is a relatively common disorder, with a lifetime prevalence of from 2 to 3%. It is probably equally common among males and females.

Patients with this disorder are plagued with recurrent obsessions or compulsions, often with both. Obsessions may manifest as recurrent thoughts, ideas, images, impulses, fears, or doubts. The obsessions are autonomous; although patients who find themselves obsessing may resist them, they are unable to stop them; they come and go on their own. Compulsions, likewise, may manifest in a variety of ways. Patients may feel compelled to touch, to count, to check, to have everything symmetrically arranged, or to repeatedly wash their hands. Attempts to resist the compulsion are met with crescendoing anxiety, which is relieved as soon as the patient gives in to the compulsion.

With the exception of children, most patients at some point recognize the senselessness of their obsessions and compulsions; yet, though their lives may be consumed by them, patients find themselves unable to stop or resist them.

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Joel Dow
Matthew Henshaw
Chris Hine
(DSM-IV-TR #296.20–296.30)

Major depressive disorder, or as it is often called, “major depression,” is characterized by the presence of one or more depressive episodes during the patient’s lifetime. Typically, a depressive episode lasts anywhere from months to years, after which most patients are generally left again in their normal state of health. Although some patients may have only one episode during their lifetime, the majority have two or more. Thus major depression is a periodic, or cyclic, illness with the patient “cycling” down into, and then up out of periods of depression. Exceptions, however, do occur. For example, in a minority of cases the depressive episode may be chronic, and an episode once begun may persist throughout the patient’s life.

Synonyms for this disorder include unipolar affective disorder; melancholia; and manic-depressive illness, depressed type. “Unipolar” highlights the critical difference between major depression and bipolar disorder, namely the fact that the patient with major depression cycles in only one direction, toward the depressive “pole,” in contrast to the patient with bipolar disorder, who cycles at times not only to the depressive pole but also at other times to the manic pole. “Melancholia” is the most ancient term for this disorder, coming to us from the Greek, meaning black bile. However, over the centuries its meaning has changed, and hence it remains open to misinterpretation. “Manic-depressive illness, depressed type,” is perhaps the least satisfactory of these synonyms. Kraepelin, as best as can be made out, felt that patients with only recurrent depression and those with both episodes of depression and episodes of mania had in fact the same illness, which he called “manic-depressive insanity.” Later clinicians, recognizing that this was probably not the case, separated the “depressed” type of “manic-depressive illness” from the “circular” type; however, this continued to cloud the fundamental distinction between these two groups of patients. Currently, at least in the United States, when one speaks of manic-depressive illness, most often one is referring to bipolar disorder, and, at least for now, this developing convention should probably be honored, and the term “manic-depressive illness, depressed type,” should probably be left in the history books.

Major depression is a common disorder. Prevalence figures vary according to methodology, but at least 5% of the general adult population has this disorder. Given, however, the relapsing and remitting nature of the depressive episodes, a lower percentage of the population is actually in the midst of a depressive episode at any given time. Again, estimates vary, with point prevalence figures ranging anywhere from 2 to 5%.

Amongst adults, major depression is seen twice as frequently among women as men; however, among children the sex ratio is equal.

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Joel Dow
Ed Downey
Ian Downey
Jeremy Dziedzic
(DSM-IV-TR #307.23)

The essential features of Tourette's Disorder are multiple motor tics and one or more vocal tics (Criterion A).

These may appear simultaneously or at different periods during the illness. The tics occur many times a day, recurrently throughout a period of more than 1 year. During this period, there is never a tic-free period of more than 3 consecutive months (Criterion B).

The onset of the disorder is before age 18 years (Criterion C).

The tics are not due to the direct physiological effects of a substance (e.g., stimulants) or a general medical condition (e.g., Huntington's disease or postviral encephalitis) (Criterion D).

The anatomical location, number, frequency, complexity, and severity of the tics change over time. Simple and complex motor tics may affect any part of the body, including the face, head, torso, and upper and lower limbs. Simple motor tics are rapid, meaningless contractions of one or a few muscles, such as eye blinking. Complex motor tics involving touching, squatting, deep knee bends, retracing steps, and twirling when walking may be present.

The vocal tics include various words or sounds such as clicks, grunts, yelps, barks, sniffs, snorts, and coughs. Coprolalia, a complex vocal tic involving the uttering of obscenities, is present in only a small minority of individuals (less than 10%) and is not required for a diagnosis of Tourette's Disorder....

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Kevin Canavan
Ariel Cruz
Phil Herford
John Horner

A specific phobia is an intense and irrational fear of a specified object or situation. There are four defined categories of specific phobias: natural, medical, animal and situational. Many people suffer multiple specific phobias simultaneously.

The DSM-IV (Diagnostic and Statistical Manual, 4th Ed.) provides specific diagnostic criteria for a simple phobia.

•Marked, Excessive Fear: A persistent and intense fear that is triggered by a specific object or situation.

•Immediate Anxiety Response: The fear reaction appears almost instantaneously when the object or situation is presented. The response may resemble a panic attack.

•Recognition That Fear Is Irrational: Adults with specific phobias recognize that their fears are out of proportion to reality. Children may not have this awareness.

•Avoidance or Extreme Distress: The sufferer goes out of his or her way to avoid the object or situation, or endures it with extreme distress.

•Life-Limiting: The phobia significantly impacts the sufferer’s school, work or personal life.

•Six Months Duration: In children and teens, the symptoms must have lasted for at least six months.

•Not Caused by Another Disorder: Many anxiety disorders have similar symptoms. The therapist will rule out other disorders before diagnosing a specific phobia.

Cymophobia, catagorized as a specific phobia, is a panic regarding waves that may be related to a fear of motion, water, or of landscapes in which water and leaves are prominent.

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Robert Braden
Ian Downey
Ben Sear
(DSM-IV-TR #307.46)

The essential feature of Sleep Terror Disorder is the repeated occurrence of sleep terrors, that is, abrupt awakenings from sleep usually beginning with a panicky scream or cry (Criterion A).

Sleep terrors usually begin during the first third of the major sleep episode and last 1–10 minutes. The episodes are accompanied by autonomic arousal and behavioral manifestations of intense fear (Criterion B).

During an episode, the individual is difficult to awaken or comfort (Criterion C).

If the individual awakens after the sleep terror, no dream is recalled, or only fragmentary, single images are recalled. On awakening the following morning, the individual has amnesia for the event (Criterion D).

The sleep terror episodes must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion E).

Sleep Terror Disorder should not be diagnosed if the recurrent events are due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (Criterion F).

Sleep terrors are also called "night terrors" or pavor nocturnus. During a typical episode, the individual abruptly sits up in bed screaming or crying, with a frightened expression and autonomic signs of intense anxiety (e.g., tachycardia, rapid breathing, flushing of the skin, sweating, dilation of the pupils, increased muscle tone). The individual is usually unresponsive to the efforts of others to awaken or comfort him or her. If awakened, the person is confused and disoriented for several minutes and recounts a vague sense of terror, usually without dream content.

Although fragmentary vivid dream images may occur, a storylike dream sequence (as in nightmares) is not reported. Most commonly, the individual does not awaken fully, but returns to sleep, and has amnesia for the episode on awakening the next morning. Some individuals may vaguely recall having an "episode" during the previous night, but do not have detailed recall. Usually only one episode will occur on any one night, although occasionally several episodes may occur at intervals throughout the night....

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Kevin Canavan
Ian Downey
Phil Herford
(DSM-IV-TR #347.00)

The essential features of Narcolepsy are repeated irresistible attacks of refreshing sleep, cataplexy, and recurrent intrusions of elements of rapid eye movement (REM) sleep into the transition period between sleep and wakefulness.

The individual's sleepiness typically decreases after a sleep attack, only to return several hours later. The sleep attacks must occur daily over a period of at least 3 months to establish the diagnosis (Criterion A), although most individuals describe many years of sleep attacks prior to seeking clinical attention. In addition to sleepiness, individuals with Narcolepsy experience one or both of the following: cataplexy (i.e., episodes of sudden, bilateral, reversible loss of muscle tone that last for seconds to minutes and are usually precipitated by intense emotion) (Criterion B1) or recurrent intrusions of elements of rapid eye movement (REM) sleep into the transition between sleep and wakefulness as manifested by paralysis of voluntary muscles or dreamlike hallucinations (Criterion B2).

Many sleep experts allow the diagnosis to be made in the absence of cataplexy or intrusions of REM sleep elements if the individual demonstrates pathological sleepiness and two or more sleep-onset REM periods during a Multiple Sleep Latency Test (MSLT). The symptoms must not be due to the direct physiological effects of a substance (including a medication) or another general medical condition (Criterion C).

Although Narcolepsy is classified in the chapter of ICD devoted to neurological conditions, it is included in this section to assist in differential diagnosis in individuals with excessive sleepiness and is coded on Axis I.

Episodes of sleepiness in Narcolepsy are often described as irresistible, resulting in unintended sleep in inappropriate situations (e.g., while driving an automobile, attending meetings, or carrying on a conversation). Low-stimulation, low-activity situations typically exaggerate the degree of sleepiness (e.g., falling asleep while reading, watching television, or attending lectures). Sleep episodes generally last 10–20 minutes but can last up to an hour if uninterrupted. Dreaming is frequently reported. Individuals have varying abilities to "fight off" these sleep attacks. Some individuals take naps intentionally in order to manage their sleepiness. Individuals with Narcolepsy typically have 2–6 episodes of sleep (intentional and unintentional) per day when untreated. Sleep episodes are usually superimposed on a more normal degree of alertness, although some individuals describe constant sleepiness of some degree....

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Jeremy Dziedzic
R. Scott Oliver
Ben Sear
(DSM-IV-TR #295.20)

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 assumption of inappropriate or bizarre postures), stereotyped movements, prominent mannerisms, or prominent grimacing

(5) Echolalia or Echopraxia

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Kevin Canavan
Phil Herford
Sara Odze
(DSM-IV-TR #312.39)

The essential feature of Trichotillomania is the recurrent pulling out of one's own hair that results in noticeable hair loss (Criterion A).

Sites of hair pulling may include any region of the body in which hair may grow (including axillary, pubic, and perirectal regions), with the most common sites being the scalp, eyebrows, and eyelashes. Hair pulling may occur in brief episodes scattered throughout the day or in less frequent but more sustained periods that can continue for hours. Hair pulling often occurs in states of relaxation and distraction (e.g., when reading a book or watching television) but may also occur during stressful circumstances. An increasing sense of tension is present immediately before pulling out the hair (Criterion B).

For some, tension does not necessarily precede the act but is associated with attempts to resist the urge. There is gratification, pleasure, or a sense of relief when pulling out the hair (Criterion C).

Some individuals experience an "itch-like" sensation in the scalp that is eased by the act of pulling hair. The diagnosis is not given if the hair pulling is better accounted for by another mental disorder (e.g., in response to a delusion or a hallucination) or is due to a general medical condition (e.g., inflammation of the skin or other dermatological conditions) (Criterion D).

The disturbance must cause significant distress or impairment in social, occupational, or other important areas of functioning (Criterion E).

Examining the hair root, twirling it off, pulling the strand between the teeth, or trichophagia (eating hairs) may occur with Trichotillomania. Hair pulling does not usually occur in the presence of other people (except immediate family members), and social situations may be avoided.

Individuals commonly deny their hair-pulling behavior and conceal or camouflage the resulting alopecia. Some individuals have urges to pull hairs from other people and may sometimes try to find opportunities to do so surreptitiously. They may pull hairs from pets, dolls, and other fibrous materials (e.g., sweaters or carpets). Nail biting, scratching, gnawing, and excoriation is often associated with Trichotillomania. Individuals with Trichotillomania may also have Mood Disorders, Anxiety Disorders (especially Obsessive-Compulsive Disorder), Substance Use Disorders, Eating Disorders, Personality Disorders, or Mental Retardation....

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