By James Morrison, M. D.
Description Table of Contents Material from a sample section
My other current books: The First Interview Medical Disorders for Psychotherapists
Evaluating Children with DSM-IV (with Thomas F. Anders, M. D.)
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Information about DSM-IV Made Easy
As anyone who has worked with it knows, DSM-IV, the fourth edition of the Diagnostic and Statistical Manual, can pose an enormous challenge for any professional person. Written by a committee and worded to satisfy the demands of the researcher, the lawyer, as well as the clinician, it may please none of them. That's why I wrote DSM-IV Made Easy--to explain the important concepts that mental health professionals need to understand and use. Here's what I've done to make DSM-IV Easy:
Whenever possible, I have simplified criteria to make them more understandable.
I have moved some of the legal-sounding language to coding notes, where it won't get in your way until you need it.
The text is interspersed with Tips. Some of these merely highlight information that will help you make a diagnosis quickly. Some are sidebars that contain historical information and other interesting sidelights about diagnosis. I also offer editorial asides--my opinions about diagnosis, patients, and clinical matters in general.
Finally, I have used that reliable teaching device, the clinical vignette. As a student, I found that I often had trouble keeping in mind the fine points of diagnosis. But once I had evaluated and treated a patient, I always had a mental image to help me remember important points about symptoms and differential diagnosis.
For each patient described (there are over 100 of them), I describe the application of DSM-IV criteria and discuss the important points in the differential diagnosis. At the end of each vignette, you will find a complete, 5-Axis evaluation.
At the end of the book is a section on evaluating the mental health patient, which includes principles for selecting the important diagnostic information and rules for formulating a rational diagnosis. I have illustrated this information with an additional 11 vignettes, on which you can test your diagnostic ability.
I have introduced each chapter with a Quick Guide -- a condensed reference that briefly outlines the important features of each diagnosis in that chapter, as well as references to disorders in other chapters that can cause similar symptoms.
In nearly 600 pages, DSM-IV Made Easy covers all the diagnoses applicable to adults, including 3 from the infant, child, and adolescent chapter (Mental Retardation, Tourette's Syndrome, Attention-Deficit/Hyperactivity Disorder). All of the criteria for the childhood diagnoses are included--in simplified form.
|1.||Delirium, Dementia, and Amnestic and Other Cognitive Disorders|
|2.||Mental Disorders Due to a General Medical Condition|
|4.||Schizophrenia and Other Psychotic Disorders|
|10.||Sexual and Gender Identity Disorders|
|13.||Impulse-Control Disorders Not Elsewhere Classified|
|16.||Disorders Usually First Diagnosed in Infancy, Childhood, and Adolescence|
|17.||Other Factors That May Need Clinical Attention|
|18.||Evaluating the Mental Health Patient|
Below, I have included all the material from an actual 4-page section of DSM-IV Made Easy.
To a considerable extent, it's a matter of taste whether to diagnose a sleep disorder that occurs secondary to another Axis I or an Axis II condition. The DSM-IV criteria state that this is appropriate when the problem with sleep is serious enough to justify an evaluation in its own right. If the patient's presenting complaint is the sleep problem, this should be considered evidence of clinical importance. However, the situation is often unclear and usually requires judgment. In the example of a mood disorder, any problem with sleep is almost certainly a symptom that will resolve once the depression has been adequately treated. Therefore, no one could be faulted for diagnosing only the mood disorder. In any event, the mood disorder should be listed first, because it is by far the more important.
As noted earlier in the chapter, sleep disturbance is primarily a symptom; insomnia is symptomatic of many mental disorders. It is often directly proportional to the severity of the mental disorder. Logically, sleep improves once the underlying symptoms have resolved. Many Axis I and II conditions and disorders often present as sleep problems, for which patients may abuse hypnotic and other medications:
DEPRESSION. Insomnia is probably most often a symptom of a mood disorder. In fact, sleep disturbance may be one of the earliest symptoms of depression. Elderly depressed patients are especially likely to have insomnia. In severe depression, terminal insomnia (awakening early in the morning and being unable to get back to sleep) is characteristic.
ANXIETY DISORDERS. The criteria for Generalized Anxiety Disorder and for Posttraumatic Stress Disorder specifically mention sleep disturbance as a symptom, but Panic Attacks may also occur during sleep.
ADJUSTMENT DISORDER. Patients who have developed anxiety or depression in response to a specific stressor may lie awake worrying about their particular stressor or the day's events.
SOMATIZATION DISORDER. Many somatizing patients will complain of problems with sleep, especially initial and interval insomnia.
COGNITIVE DISORDERS. Most demented patients have some degree of sleep disturbance, typically interval awakening. They wander at night and suffer from reduced alertness during the day.
MANIC AND HYPOMANIC EPISODES. In a 24-four hour period, manic and hypomanic patients typically sleep less than they do when they are euthymic. However, they do not complain of insomnia. They feel rested and ready for more activity; their families and friends are the ones who become concerned. If they (or their relatives) do complain, it is usually of lengthened sleep onset latency (the time it takes to fall asleep).
SCHIZOPHRENIA. When they are becoming ill, delusions, hallucinations, or anxiety may keep schizophrenic patients preoccupied later and later into the night. Total sleep time may remain constant, but they arise progressively later, until most of their sleeping occurs during the day. DSM-IV does not provide a way to code a circadian rhythm disorder related to an Axis I disorder; Insomnia Related to Schizophrenia is about the best we can do.
OBSESSIVE-COMPULSIVE PERSONALITY DISORDER. This personality disorder is commonly cited as an Axis II disorder associated with insomnia.
Anxiety or mania may mask an insomnia that occurs in the course of an Axis I disorder. Patients may not recognize a sleep deficit until they fall asleep at the wheel or suffer an industrial accident. On the other hand, clinicians sometimes focus on the problem with sleep and underdiagnose the underlying mental problem.
For at least a month, the patient's main complaint has been trouble going to sleep, trouble staying asleep, or feeling unrested.
The insomnia causes daytime fatigue or impairs daytime functioning.
The insomnia (or its daytime results) causes clinically important distress or impairs work, social, or personal functioning.
Although it is serious enough to warrant clinical attention, the clinician believes that another Axis I or II disorder (such as Generalized Anxiety Disorder, Major Depressive Disorder, or Adjustment Disorder) causes it.
Another sleep disorder (such as a parasomnia, Narcolepsy, or Breathing-Related Sleep Disorder) does not explain the symptoms better.
The insomnia is not directly caused by a general medical condition or by the use of substances, including medications.
Use the name of the actual related mental disorder in the Axis I sleep disorder diagnosis. Also, code the mental disorder itself on Axis I or II, as appropriate.
"I'm just not getting enough sleep to play." Sal
Camozzi was a third-year student who attended a small liberal arts college in
southern California on a football scholarship. Now it was early November, midway
through the season, and he didn't think he could keep up the effort. He had
always kept regular hours and "eaten healthy," but for over a month he
had been awakening at 2:30 every morning.
"I might as well be setting an alarm," he said. "My eyes click open and there I am, worrying about the next game, or passing chemistry, or whatever. I'm only getting five hours at night, and I've always needed eight. I'm getting desperate."
For a while Sal had tried over-the-counter sleep medications. They helped a little, but mainly they made him feel groggy the next day. He gave them up; he had always avoided alcohol and drugs, and hated the feeling of chemicals in his body.
Sal had had something of the same problem the previous fall, and the one before that. Then he had had the same difficulty with sleep; his appetite had fallen off, too. Neither time had things been as severe as now, however. (This year he had already lost 10 pounds; as a linebacker, he needed to keep his weight up.) Sal also complained that he just didn't seem to enjoy life in general the way he usually did. Although his interest in football and his concentration on the field had diminished, it hadn't been as bad last year, and he had finished the season with respectable statistics.
One summer during high school, Sal had felt listless and slept too much. He'd been tested for infectious mononucleosis and found to be physically well. He was his normal self by the time school started that fall.
Last spring and the one before had been a different matter. When Sal went out for baseball, he seemed to explode with energy, batted .400, and played every game. He didn't sleep much then, either, when he came to think of it, though five hours a night had seemed plenty. "I had loads of energy and never felt happier in my life. I felt like another Babe Ruth."
The coach had noted that Sal had been "terrific during baseball season, all hustle, but he talked too much. Why doesn't he put the same effort into football?"
Evaluation of Sal Camozzi
From Sal's history, he did not have a Substance-Induced Sleep
Disorder or one related to a general medical condition. There was
similarly no evidence for another sleep disorder.
Sal's sleep difficulty was actually only the tip of his depressive iceberg. The first thing to look for would be other symptoms of a Major Depressive Episode. Although he didn't complain in so many words of feeling depressed, he did report a general loss of zest for life. Besides that and the insomnia, Sal had also lost his appetite, interest, and concentration. Together, his symptoms would barely meet criteria for a Major Depressive Episode. The history did not touch on death wishes or suicidal ideas; it should have.
Besides depression, the obvious episodes of high mood would need to be considered in the diagnosis. Sal had had several periods when he felt unusually happy, his energy level increased, he talked a great deal, and his need for sleep decreased. Especially in contrast to his present mood, his self-esteem was markedly increased (he noted that he felt like Babe Ruth). This change in his mood was pronounced enough that others noticed and commented on it, but it did not compromise his functioning or require hospitalization (it would have then instead been diagnosed as a Manic Episode). These symptoms would fulfill criteria for a Hypomanic Episode.
All of this would add up to a diagnosis of Bipolar II Disorder (see p. 210); Sal's current episode would be designated Depressed. He would qualify for none of the episode specifiers, though he would nearly meet the criteria for With Melancholic Features. However, his history of repeated depressions beginning in the same season of the year (fall, in this instance) and consistently either resolving or switching to hypomania during another season (spring) would be typical for the course specifier With Seasonal Pattern. Although Sal may have had one episode of depression when he was in high school that did not fit this pattern, most of the episodes did. And the last two years fit the mold exactly.
Sal's sleeplessness would have been clinically significant even without the Bipolar II Disorder, and this would meet the DSM-IV criteria for coding it. As always, however, the diagnosis most in need of clinical intervention would be listed first:
||Bipolar II Disorder, Depressed, With Full
Interepisode Recovery, With Seasonal Pattern
|307.42||Insomnia Related to Bipolar II Disorder|
|Axis II||V71.09||No diagnosis|
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