Notes on Diagnostic and Statistical Manual IV (DSM IV)

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Axis of diagnosis:

I: clinical disorders.

II: personality disorders and mental retardation.

III: physical disease.

IV: social problems.

V: GAF; global assessment of function.

Mental retardation:

• Axis II.

• Fetal alcohol syndrome is most common cause.

• Fragile X and down are most common genetic causes.


• Axis I.

• Delayed language; social problems.

• Chromosome 15.

• Defective neural circuits; failure of apoptosis.



• Methylphenidate, dextroamphetamine, pemoline.


Causes of Schizophrenia:

• Trinucleotide repeat amplification; birth trauma.

Types of Schizophrenia:


• Delusions, hearing voices, etc.


• State of shock/confusion; stuck in awkward positions for long periods of time; repetitious.


• Incoherent, primitive, unorganized behavior and speech, explosive laughter.

Signs of Schizophrenia:

• Cannot follow slow moving object with the eye.

• Slower to fix impressions in short-term memory.

• Diminished amplitude of auditory P300; impaired selective attention.

• Prefrontal cortical (PFC) impairment; cannot perform complicated cognitive tasks.

Schizophrenia Pathology:

• Site of primary schizophrenic pathology: limbic system.

Mood disorders:


• Chronic depression greater than 2 years.

• Changes in appetite, sleep, self-esteem, hopelessness, etc.


• Nonpsychotic bipolar.

• Alternating states.

Seasonal affective disorder:

• Depression during winter.

• Treatment: bright light therapy.

• Abnormal melatonin metabolism.

Unipolar depression:

• Major depression greater than 2 weeks.

• Anhedonia, delusions, hallucinations, suicide risk, disturbed sleep patterns.

• Abnormally high glucose metabolism in amygdala; smaller hippocampus, increased glucocorticoids.

• Decreased NE, 5-HT, and DA.

• Early morning awakening.

Bipolar disorder:

• Unipolar disorder + mania (mood swings).

• I: more mania.

• II: more depression.


• Increased self-esteem, low tolerance, flight of ideas, weight loss, increased libido.

• Increased NE, 5-HT, DA.

• Less common than unipolar.

Depression labs:

• Low MHPG.

• Dexamethasone doesn't suppress cortisol.

• TRH doesn't increase TSH.

• NOTE: Patient with bipolar disorder must not be given TCAs else patient will suffer a prolonged maniac episode. The depressive phase of bipolar disorder must be clearly differentiated from regular depression.

Eating disorders:

Bulimia nervosa:

• Ingestion of food followed by self-induced vomiting.

• Treatment: imipramine, SSRIs.

Anorexia nervosa:

• Self-starvation.

• Treatment: cyproheptadine, chlorpromazine, amitriptyline.

Anxiety disorders:

• Most common psychiatric disorder in women.

Generalized anxiety disorder:

• Less than 6 months.

• Pounding heart, sweating, chest pains, hyperventilation, impatient, hyperactive, distracted.



• Fear of open spaces.


• Fear of social situations; treatment: phenelzine (MAO inhibitor), or paroxetine (SSRI).

Obsessive-Compulsive Disorder:

• Obsessive: focus on one thought to avoid another.

• Compulsive: repetitive actions.

• Increased frontal lobe and caudate nucleus activity.


• Fluoxetine, fluvoxamine, SSRIs, clomipramine.

Panic disorder:

• 3 attacks in 3 weeks.

• Fear, trembling, sweating, hyperventilation.


• Alprazolam, tricyclic antidepressants, clonazepam, SSRIs, CO2.

Somatoform disorders:

Somatization disorder:

• Unexplained physical symptoms without medical cause; 8 or more symptoms: 4 pain, 2 GI, 1 sexual, 1 pseudoneurologic.

• Unconscious.

Conversion disorder:

• Unexplained physical symptoms without medical cause; 1 or more symptom.

• Unconscious.


• Preoccupation with illness when none is present.

• Greater than 6 months.

Somatoform pain disorder:

• Prolonged, unexplained pain.

• Looking for secondary gain.

• Unconscious.

Body dysmorphic disorder:

• Sees oneself as ugly or horrific when normal in appearance.


• Conscious; secondary gain.

Factitious disorder:

• Conscious and unconscious.

• Primary or secondary gain.

Post-traumatic stress disorder:

• Following a stressful situation in life.

• Flashbacks.

• Greater than 1 month.

• Less than 1 month = acute stress disorder.

Disassociative disorder:

• Triggered by emotional crisis.

• New identity, sudden travel, inability to recall past.

• Multiple personality disorder: Presence of 2 or more personalities.

• Depersonalization disorder: experienced detachment from one's body.

Personality disorders:

Type A Personality disorder:

• Paranoid: suspiciousness/mistrust of others; grudges; reads hidden meanings.

• Schizoid: social withdrawal; isolated; loner.

• Schizotypal: odd, weird, strange, magical thinking.

Type B Personality disorder:

• Histrionic: dramatic, attention-seeking, seductive behavior.

• Narcissistic: fantasy of unlimited wealth, power; fragile self-esteem; prone to depression; criticism met with rage.

• Borderline: unstable affect, behavior, self-mage; promiscuity, gambling, over-eating, drug-abuse; history of sexual abuse; self-mutilation. More in women.

• Antisocial: more in males; criminal acts; can't conform to social norm; can't hold steady job.

Type C Personality disorder:

• Avoidant: very sensitive to rejection; shy; very anxious.

• Obsessive-compulsive: orderliness, inflexible, perfectionist; rules, lists, order; stubborn; no sense of humor.

• Dependent: depends on others; assumes others to assume responsibility.

Additional Reading:

Basic Psychiatry

1. Diagnostic and Statistical Manual IV (DSM IV)
2. Organic Disorders
3. Major Depressive Disorder vs Dysthymic Disorder
4. What is Classical Conditioning?
5. What is Observational Conditioning?
6. What is Operant Conditioning?
7. How to break bad news to a patient
8. What is Dementia?
9. What is Normal Aging?
10. Factors Promoting Poor Prognosis in Schizophrenia
11. Factors Promoting Good Prognosis in Schizophrenia
12. What are Temper Tantrums?

Related Topics

1. Mechanics of Defense Mechanisms
2. Types of Antipsychotics

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