Chapters & DSM-5 Summaries

Ch. 13 Trauma and Stressor-Related Disorders

1. Post-Traumatic Stress Disorder (PTSD)

DSM-5 Criteria

  • Exposure to actual or threatened death, serious injury, or sexual violence (directly, witnessing, learning it happened to a close friend/family, or repeated extreme exposure to details).
  • Intrusive symptoms (memories, flashbacks, nightmares).
  • Avoidance of stimuli associated with the trauma (memories, thoughts, external reminders).
  • Negative alterations in cognitions and mood (e.g., guilt, fear, distorted blame).
  • Alterations in arousal and reactivity (hypervigilance, exaggerated startle response, irritability).
  • Duration >1 month; causes clinically significant distress or impairment.

Main Treatments

  • Psychotherapy: Trauma-focused CBT, EMDR.
  • Medications: SSRIs (paroxetine, sertraline) first-line; SNRIs; prazosin for nightmares.

Black Box Warnings

  • SSRIs: Increased risk of suicidal thoughts/behaviors in children, adolescents, young adults.

Common Contraindications

  • Caution with MAOIs (serotonin syndrome).
  • History of bipolar disorder (risk of inducing mania).

2. Acute Stress Disorder

DSM-5 Criteria

  • Exposure to a traumatic event similar to PTSD.
  • 9+ symptoms across intrusion, negative mood, dissociation, avoidance, arousal.
  • Duration: 3 days to 1 month after trauma.
  • Significant distress or impairment.

Main Treatments

  • Short-term Psychotherapy (CBT, anxiety management).
  • Possible short-term anxiolytics or beta-blockers for intense anxiety/panic.

Black Box Warnings & Contraindications

  • Benzodiazepines: Watch for dependence, respiratory depression.
  • SSRIs: Suicide risk warning in younger populations.

3. Adjustment Disorders

DSM-5 Criteria

  • Emotional/behavioral symptoms in response to a stressor within 3 months of onset.
  • Marked distress out of proportion to the severity/intensity of the stressor.
  • Significant impairment in social, occupational, or other functioning.
  • Not meeting criteria for another mental disorder; symptoms < 6 months after stressor ends.

Main Treatments

  • Brief Psychotherapy (individual/group).
  • Supportive counseling, problem-solving approaches.
  • Medications (e.g., short-term anxiolytics) if severe anxiety/depression.

Black Box Warnings & Contraindications

  • Antidepressants: Suicidality warning in younger patients.
  • Benzodiazepines: Caution if history of substance abuse.
Ch. 14 Anxiety and Anxiety Disorders

General Anxiety-Related Criteria

  • Excessive fear and anxiety, plus behavioral disturbances.
  • Significant distress or functional impairment.
  • Varies by triggers (social phobia, specific phobias, panic attacks).

1. Generalized Anxiety Disorder (GAD)

DSM-5 Criteria

  • Excessive anxiety/worry ≥ 6 months about various events/activities.
  • Difficulty controlling the worry.
  • ≥3 symptoms: restlessness, fatigue, concentration difficulties, irritability, muscle tension, sleep disturbance.
  • Significant distress/impairment.

Main Treatments

  • SSRIs (paroxetine, escitalopram), SNRIs (duloxetine).
  • Buspirone, CBT.
  • Short-term benzodiazepines if necessary.

Black Box Warnings

  • SSRIs/SNRIs: Increased suicide risk in younger populations.

Common Contraindications

  • Benzodiazepines: Avoid in severe respiratory insufficiency, sleep apnea, or with other CNS depressants.
  • SSRIs + MAOIs: Risk of serotonin syndrome.

2. Panic Disorder

DSM-5 Criteria

  • Recurrent, unexpected panic attacks (sudden onset of intense fear).
  • ≥1 month of persistent concern about additional attacks or maladaptive behavior change.
  • Can be with/without agoraphobia.

Main Treatments

  • SSRIs (paroxetine, sertraline) or SNRIs.
  • CBT (relaxation, breathing techniques).

Black Box Warnings & Contraindications

  • SSRIs: Suicide risk warning.
  • Benzodiazepines: Dependence, avoid other sedatives.

3. Phobic Disorders

DSM-5 Criteria

  • Persistent, excessive, or unreasonable fear of object/situation (e.g., heights, social scrutiny).
  • Exposure triggers immediate anxiety or panic.
  • Fear is out of proportion, causing significant distress or impairment.

Main Treatments

  • CBT with exposure therapy (systematic desensitization).
  • SSRIs for social phobia; beta-blockers (propranolol) for performance anxiety.

Black Box Warnings & Contraindications

  • SSRIs: Suicidality in youth.
  • Beta-blockers: Caution in asthma, heart block, bradycardia.
Ch. 15 Obsessive–Compulsive and Related Disorders

Obsessive-Compulsive Disorder (OCD)

DSM-5 Criteria

  • Obsessions (intrusive, unwanted thoughts) and/or compulsions (repetitive behaviors/mental acts).
  • Behaviors/thoughts are excessive or not realistically helpful.
  • Time-consuming (>1 hour/day) or cause distress/impairment.

Main Treatments

  • High-dose SSRIs (fluoxetine, sertraline).
  • Exposure and Response Prevention (ERP) therapy.

Black Box Warnings

  • SSRIs: Suicidality in children/young adults.

Common Contraindications

  • SSRIs + MAOIs: Serotonin syndrome risk.
  • Avoid abrupt SSRI discontinuation (withdrawal).

Body Dysmorphic Disorder

DSM-5 Criteria

  • Preoccupation with >1 perceived defects in appearance (slight or unobservable to others).
  • Repetitive behaviors (mirror checking) or mental acts (comparing).
  • Causes significant distress or impairment.

Main Treatments

  • SSRIs + CBT to address distortions and compulsive behaviors.

Black Box Warnings & Contraindications

  • SSRIs: Suicidality watch.
  • Caution if co-occurring depression or eating disorder.

Trichotillomania & Excoriation Disorder

DSM-5 Criteria

  • Trichotillomania: Recurrent hair pulling, hair loss, attempts to stop.
  • Excoriation: Recurrent skin picking, causing lesions, attempts to stop.
  • Significant distress/impairment.

Main Treatments

  • Habit Reversal Training (CBT).
  • SSRIs or other meds (e.g., N-acetylcysteine) for urges.

Black Box Warnings & Contraindications

  • SSRIs: Suicidality in young.
  • Benzodiazepines: Addiction potential if used for severe anxiety.
Ch. 17 Mood Disorders and Suicide

Major Depressive Disorder (MDD)

DSM-5 Criteria

  • ≥5 symptoms in a 2-week period: depressed mood, anhedonia, weight/appetite change, sleep disturbance, psychomotor changes, fatigue, worthlessness/guilt, poor concentration, suicidal ideation.
  • Clinically significant distress/impairment.
  • No manic/hypomanic episodes.

Main Treatments

  • SSRIs (first-line), SNRIs, TCAs, psychotherapy (CBT, interpersonal therapy).
  • ECT for resistant or severe depression.

Black Box Warnings

  • All antidepressants: Increased suicidality in young people.

Common Contraindications

  • MAOIs require 2-week washout before SSRIs.
  • Caution in bipolar (risk of manic switch).

Bipolar I Disorder

DSM-5 Criteria

  • ≥1 manic episode (elevated/irritable mood, increased energy ≥1 week or hospitalization).
  • May have depressive or hypomanic episodes (not required for diagnosis).

Main Treatments

  • Mood Stabilizers (lithium, valproate), antipsychotics, benzodiazepines for acute mania.
  • Psychotherapy after mood stabilization.

Black Box Warnings

  • Lithium: Narrow therapeutic index; watch toxicity.
  • Valproic Acid: Hepatotoxicity, pancreatitis, teratogenicity.
  • Antipsychotics: Increased mortality in elderly with dementia-related psychosis.

Common Contraindications

  • Lithium: Renal/thyroid disease, dehydration, sodium depletion.
  • Valproic acid: Liver disease, pregnancy (birth defects).
Ch. 20 Eating Disorders

Anorexia Nervosa

DSM-5 Criteria

  • Restriction of energy intake leading to significantly low body weight.
  • Intense fear of weight gain or persistent behavior interfering with weight gain.
  • Distorted body image or undue influence of weight on self-evaluation.

Main Treatments

  • Nutritional rehabilitation, psychotherapy (Family-Based Therapy, CBT).
  • Monitor for refeeding syndrome (electrolytes).
  • SSRIs post-weight restoration for anxiety/depression.

Black Box Warnings

  • Antidepressants: Suicidality in youth.
  • Refeeding: Cardiac complications risk in severe anorexia.

Common Contraindications

  • Bupropion contraindicated (seizure risk).
  • Avoid rapid refeeding (refeeding syndrome).

Bulimia Nervosa

DSM-5 Criteria

  • Binge eating followed by compensatory behaviors (vomiting, laxatives, exercise) at least once/week for 3 months.
  • Self-evaluation influenced by body shape/weight.
  • Not exclusive to anorexia episodes.

Main Treatments

  • CBT is gold-standard.
  • SSRIs (fluoxetine FDA-approved).
  • Nutritional counseling, medical monitoring for electrolytes.

Black Box Warnings

  • Fluoxetine: Suicidality risk in youth.
  • Cardiac arrhythmias in severe electrolyte imbalance.

Common Contraindications

  • Bupropion again contraindicated (seizure risk).
  • Caution with other serotonergic agents (serotonin syndrome).
Ch. 21 Somatic Symptom Illnesses

Somatic Symptom Disorder

DSM-5 Criteria

  • ≥1 somatic symptoms causing significant distress or disruption.
  • Excessive thoughts/behaviors related to the symptoms.
  • Persistent for ≥6 months.

Main Treatments

  • CBT, frequent but brief medical check-ins.
  • SSRIs if comorbid anxiety/depression.

Black Box Warnings & Contraindications

  • SSRIs: Suicidality in youth.
  • Avoid benzodiazepine overuse in health-anxious patients.

Illness Anxiety Disorder

DSM-5 Criteria

  • Preoccupation with having a serious illness, minimal/no somatic symptoms.
  • High anxiety about health, excessive behaviors or avoidance.
  • Preoccupation ≥6 months.

Main Treatments

  • CBT for misinterpretation of bodily symptoms.
  • SSRIs if severe anxiety/depression.

Black Box Warnings & Contraindications

  • SSRIs: Same suicidality caution.
  • Encourage a single primary care provider to reduce excessive testing.

Conversion Disorder (Functional Neurological Symptom Disorder)

DSM-5 Criteria

  • ≥1 symptoms of altered motor/sensory function (e.g., paralysis, blindness) without medical explanation.
  • Causes significant distress/impairment.

Main Treatments

  • CBT or therapy focusing on stress/conflict.
  • Physical therapy to maintain function if needed.

Black Box Warnings & Contraindications

  • Psychotropics: Suicidality with antidepressants.
  • Rule out medical causes before diagnosing conversion.

Factitious Disorders (Munchausen)

DSM-5 Criteria

  • Falsification of signs/symptoms, or induction of injury/disease for the sick role.
  • No obvious external rewards (vs. malingering).

Main Treatments

  • Careful confrontation, psychotherapy for underlying issues.

Black Box Warnings & Contraindications

  • If on meds, watch for medication misuse by patient.
  • Risk of repeated invasive procedures/tests.
Ch. 22 Neurodevelopmental Disorders

Autism Spectrum Disorder (ASD)

DSM-5 Criteria

  • Persistent deficits in social communication/interactions across multiple contexts.
  • Restricted, repetitive patterns of behavior/interests/activities.
  • Symptoms present in early developmental period; cause impairment.

Main Treatments

  • Early Intensive Behavioral Interventions (ABA).
  • Speech & occupational therapy.
  • Antipsychotics (risperidone) for severe irritability/aggression if needed.

Black Box Warnings & Contraindications

  • Antipsychotics: Increased mortality in elderly with dementia, sedation/metabolic issues in kids.
  • Caution with polypharmacy.

Attention-Deficit Hyperactivity Disorder (ADHD)

DSM-5 Criteria

  • Inattention and/or hyperactivity-impulsivity before age 12 in ≥2 settings.
  • Interferes with social, academic, or occupational functioning.

Main Treatments

  • Stimulants (methylphenidate, amphetamines) first-line.
  • Non-stimulants (atomoxetine, guanfacine) if contraindicated.
  • Behavioral therapy, parent training.

Black Box Warnings

  • Stimulants: High abuse potential, sudden death in cardiac abnormalities.
  • Atomoxetine: Suicidal ideation risk in kids/adolescents.

Common Contraindications

  • Stimulants: Avoid in structural heart disease, severe anxiety, psychosis.
  • Atomoxetine: Caution in severe cardiovascular disorders.
Ch. 23 Disruptive Behavior Disorders

Oppositional Defiant Disorder (ODD)

DSM-5 Criteria

  • Pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness for ≥6 months.
  • ≥4 symptoms from these categories, at least one non-sibling interaction.
  • Significant problems in home, school, or work.

Main Treatments

  • Parent-child interaction therapy, family therapy, behavior management.
  • Medications if comorbid conditions (ADHD, anxiety).

Black Box Warnings & Contraindications

  • If ADHD is comorbid, see stimulant black box warnings.
  • Avoid antipsychotic overuse unless severe aggression documented.

Conduct Disorder

DSM-5 Criteria

  • Repetitive, persistent pattern of violating others' rights or major societal norms (aggression, property destruction, theft, rule violations).
  • ≥3 criteria in past 12 months, ≥1 in last 6 months.

Main Treatments

  • Multisystemic therapy, family therapy, behavior modification.
  • Possible medications for aggression or comorbid conditions.

Black Box Warnings & Contraindications

  • Antipsychotics (for severe aggression): Increased mortality in elderly with dementia.
  • Monitor stimulant misuse if comorbid ADHD.

Specific Points from Professor