history, DSM, Depression

2. Psychology: The study of the nature,
functions and phenomena of behavior
and mental experience.
Abnormal Psychology: A branch of
psychology devoted to the study of the
classification, etiology, diagnosis and
prevention of mental disorders and
disabilities. Also called Psychopathology.

3. Picture shows a skull with a whole pierced
into it to release evil spirits, done in ancient
times.
Ancient people regarded mentally-ill
people as being possessed by evil
spirits, and apparently used trephining,
piercing a hole in the skull of the
afflicted person, in an attempt to
release these spirits.

4. Later, in ancient Greece, Hippocrates viewed abnormality
as the result of imbalance among 4 fluids, or biles, in the
body. Excess in one of the biles caused the person to
display some particular behaviors.
According to humoralism, four bodily fluids determined a
person's temperament and an imbalance led to certain
sicknesses dependent upon which humors were in excess
or deficit.

5. In the Middle Ages, the belief that abnormal
behavior is caused by demonic possession was
reflected in the “treatments” given to the mentally
ill, these “treatments” were administered by the
religious authorities, and included all types of
procedures to purge the afflicted person of the
demons.
This picture shows a woman tied up on a ladder
and about to be burnt alive.

8. Deviation from social norms
 Social norms are a set of rules for behavior
based on a set of moral and conventional
standards within society.
 The unwritten rules of behavior that are
considered acceptable in a group or society.
 They are judged by the dominant culture.

9. Unwritten social norms
 Being polite
 Opening doors for people
 Not hearing voices (Schizophrenia)
 Not washing your hands 50 times a day
 Queueing in shops
 Not standing too close to people when talking
 Wear clothes when walking around outside
These are just a few examples which give an indication of abnormal behavior

10. However…
There would be serious problems if we tried to use
social norms to define normality and abnormality

11. Social norms vary from one culture
or society to another

12. What is seen as normal behavior in the
dominant culture
John Maguire and Laurence Scott-Mackay were the first couple to exchange vows in a civil partnership
ceremony in Scotland, With a Ceremony in Edinburgh.

13. Social norms also vary from one time to another
On 25 May 1895 Wilde was
convicted of gross
indecency and sentenced to
two years’ hard labour.

14. It is unclear how far a person could deviate from
social norms before being defined as abnormal
Tattoos and piercings are now accepted as normal but even
these may sometimes viewed as abnormal… does this
indicates psychological abnormality?

15. statistical deviation
 Behaviours, emotional reactions and patterns of thinking
which are statistically rare (atypical) or deviate from the
statistical average or norm are classified as abnormal.
 The statistical definition hinges on the idea that abnormality
can be measured using quantitative data and thus one
individual can be compared with another.
 Statistical norms are established using a normal distribution
curve which illustrates the fact that most people, (approx
95%) score between one and two standard deviation above or
below the mean average.
 This leaves just over 2% of people who score unusually high
or low and these people would be classed as abnormal
because they are not typical of most people.
Deviance from statistical norms

16. statistical deviation
 When diagnosing depression for example, a structured
interview or questionnaire including closed questions may be
used and quantitative data can be derived; once the practitioner
has calculated the individual’s ‘score’, this can be compared to
statistical norms and a decision made about whether the person
has a score which is high/low enough to be classed as
abnormal.
 With regard to intelligence the standard deviation is 15 and the
average is 100, this means that anyone who scores over 130 or
under 70 will be classed as abnormal since these scores are two
standard deviations above and below the mean.

17. Prep
Advantages, disadvantages of this approach…

18. The Diagnostic and Statistical Manual of Mental Disorders (DSM) how
exactly define mental disorder?
A clinically significant behavioral or psychological syndrome or pattern which is associated
with present distress or disability or with a significantly increased risk of suffering death,
pain, disability, or an important loss of freedom.
 Must not be merely an expectable and culturally sanctioned response to a particular event,
for example, the death of a loved one
 A manifestation of a behavioral, psychological, or biological dysfunction in the individual
 Neither deviant behavior (e.g., political, religious, or sexual) nor conflicts that are primarily
between the individual and society are mental disorders unless the deviance or conflict is a
symptom of a dysfunction in the individual

19. Introduction to DSM
The Diagnostic and Statistical Manual of Mental Disorders (DSM) was created in 1952 by
the American Psychiatric Association so that mental health professionals in the United States
would have a common language to use when diagnosing individuals with mental disorders.
It is the handbook used by health care professionals as the authoritative guide to the diagnosis
of mental disorders.
DSM contains descriptions, symptoms, and other criteria for diagnosing mental disorders.
Used by clinicians and researchers to diagnose and classify mental disorders,
the criteria are concise and explicit, intended to facilitate an objective assessment of symptom
presentations in a variety of clinical settings—inpatient, outpatient, partial hospital,
consultation-liaison, clinical, private practice, and primary care.

20. Revision of DSM
 TheAP
Aprepared for the revision of DSM for nearly a decade, with an unprecedented process
of research evaluation that included a series of white papers and 13 scientific conferences
supported by the National Institutes of Health.
 This preparation brought together almost 400 international scientists and produced a series
of monographs and peer-reviewed journal articles.
1952
1968
1980
1987
1994
DSM-I
DSM-II DSM-III-R
DSM-III
DSM-IV-TR
DSM-IV 2000 DSM-5
2013

21. Diagnostic and Statistical Manual of Mental Disorders (DSM)
Edition Publication
Date
Number of
Pages
Number of
Diagnoses
Number of
Disorders
DSM-I 1952 132 128 106
DSM-II 1968 119 193 182
DSM-III 1980 494 228 265
DSM-III-R 1987 567 253 292
DSM-IV 1994 886 383 297
DSM-IV-TR 2000 943 383
DSM-5 2013 947 541 312

22. DSM-I (1952)
The first edition of DSM (1952) was titled 'Diagnostic and Statistical
Manual of Mental Disorders'. It did not carry any number attached to its
title.
DSM-I was created after World War II, and was partially a reaction to the
return of military veterans from the war. Many veterans showed non-
psychotic but non-physical disorders, and a number of military medical
officers from World War II turned their attention to the treatment of these
disorders.
The DSM-I contained 128 categories. Organizationally, it had a hierarchical
system in which the initial node in the hierarchy was differentiating organic
brain syndromes from “functional” disorders which were subdivided into
psychotic versus neurotic versus character disorders.
DSM contained a glossary of descriptions of the diagnostic categories and
was the first official manual of mental disorders to focus on clinical use.

23. DSM-II (1968)
DSM II listed 182 disorders, and was 134 pages long. It was quite similar to the DSM-I.
The term "reaction" was dropped, but the term "neurosis" was retained.
In the 1960s, there were many challenges to the concept of mental illness itself. These
challenges came from sociologists, behavioral psychologists and psychiatrists like
Thomas Szasz, who argued mental illness was a myth used to disguise moral conflicts.
Unlike the DSM-I, many of the new categories added in the DSM-II were categories of
relevance to outpatient mental health efforts. Anxiety disorders, depressive disorders,
personality disorders (PDs), and disorders of childhood/adolescence were larger subsets
than they had been in the DSM-I.
LIMITATIONS:
Fleiss and Spitzer concluded "there are no diagnostic categories for which reliability
is
uniformly high. Reliability appears to be only satisfactory for three categories:
mental deficiency, organic brain syndrome, and alcoholism.

24. Sixth printing of the DSM-II (1968)
As described by Ronald Bayer, a psychiatrist and gay rights activist, specific
protests by gay rights activists against theAPAbegan in 1970.
After a vote by theAPAtrustees in 1973, and confirmed by the wider APA
membership in 1974, the diagnosis was replaced with the category of "sexual
orientation disturbance".
Homosexuality removed as a mental disorder following the protests at the
1974 annual convention of theAPAin San Francisco.

25. DSM-III (1980)
Work began on DSM–III in 1974, with publication in 1980.
• DSM-III heralded a paradigm shift in the history of psychiatric diagnosis, with its
incorporation of empirically-based, a theoretical and agnostic criteria for psychiatric
diagnosis.
• Other criteria, and potential new categories of disorder, were established by consensus
during meetings of the committee, as chaired by Spitzer.
DSM–III introduced a number of important innovations, including:
• Explicit diagnostic criteria
• Amultiaxial diagnostic assessment system.
• An approach that attempted to be neutral with respect to the causes of mental disorders.
• It was developed with the additional goal of providing precise definitions of mental
disorders for clinicians and researchers.

26. DSM-III-R (1987)
• APA appointed a work group to revise DSM–III, which developed the
revisions and corrections that led to the publication of DSM–III–R in
1987.
• Categories were renamed and reorganized, and significant changes in
criteria were made. Six categories were deleted while others were
added.
• Controversial diagnoses, such as pre-menstrual dysphoric disorder and
masochistic personality disorder were considered and discarded.
• "Ego-dystonic homosexuality" was also removed.

27. DSM-IV (1994)
• Numerous changes were made to the classification (e.g., disorders were
added, deleted, and reorganized), to the diagnostic criteria sets, and to
the descriptive text.
• A major change was the inclusion of a clinical significance criterion to
almost half of all the categories, which required symptoms cause "clinically
significant distress or impairment in social, occupational, or other impo
rtant areas of functioning".
• Some personality disorder diagnoses were deleted or moved to the appendix.

28. Axis I:
Clinical
Syndromes
Described clinical
symptoms that cause
significant impairment.
Disorders were grouped
into different categories
such as mood disorders,
anxiety disorders, or
eating disorders.
Described long-
term problems in
functioning that
were not considered
discrete axis I
disorders.
These include
such things as
unemployment,
relocation,divorce,
or the death of a
loved one.
Allowed the clinician to
rate the client's overall
level of functioning.
Based on this
assessment, clinicians
could better understand
how the other four axis
interacted and the effect
on the individual's life.
DSM-IV-TR (2000)
• The DSM-IV-TR described disorders using five different dimensions.
• This multiaxial approach was intended to help clinicians and psychiatrists make comprehensive
evaluations of a client's level of functioning because mental illnesses often impact many different life areas.
Axis II:
Personality
and
Mental Retardation
Axis III:
Medical
Conditions
Axis IV:
Psychosocialand
Environmental
Problems
Axis V:
GlobalAssessment of
Functioning or Child
GlobalAssessment of
Functioning
These included physical
and medical conditions
that influence or worsen
Axis 1 andAxis II
disorders.
Some examples include
HIV/AIDS and brain
injuries.

29. DSM-5 (2013)
• Dr. Dilip Jeste, the then President of the American Psychiatric Association,
released the Fifth Edition of the Diagnostic and Statistical Manual of Mental
Disorders on May 18, 2013 at the 166 th Annual Meeting of the APA at San
Francisco.
• As the process of developing the manual progressed, the Roman numerical 'V' was
replaced by the alpha numerical '5'. This would facilitate subsequent revisions being
numbered as 5.1, 5.2 and so forth.
• It is an authoritative volume that defines and classifies mental disorders in order to
improve diagnoses, treatment, and research. It does not claim to be the ultimate or
the final word in classification of mental disorders.
• Some examples of categories included in the DSM-5 include anxiety disorders,
bipolar and related disorders, depressive disorders, feeding and eating disorders,
obsessive-compulsive and related disorders, and personality disorders.

30. DSM-5:
It is a 947 page manual, divided into three sections and an appendix:
Section
Includes:
Introduction, Instruction on
how to use the manual, and a
chapter on cautionary
of DSM 5.
statement for forensic use axis format and considers
the relevance of age,
gender, and culture.
Covers:
Self-rated cross-cutting
symptom measures for
adults, children, and
adolescents between age
6 and 17 years.
01 02 03
Section Section
Lists:
Diagnostic criteria and
codes of 22 diagnostic
categories. It has a single

31. Changes in The DSM-5
It eliminated the axis system, instead listing categories of disorders along
with a number of different related disorders.
Asperger's disorder was removed and incorporated under the category of a
utism spectrum disorders.
Disruptive mood dysregulation disorder was added, in part to decrease
over-diagnosis of childhood bipolar disorders.
Several diagnoses were officially added to the manual including binge
eating disorder, hoarding disorder, and premenstrual dysphoric disorder.
It is based on explicit disorder criteria, which taken together constitute a
“nomenclature” of mental disorders, along with an extensive explanatory text that is
fully referenced for the first time in the electronic version of this DSM.

32. Depressive Disorders

34. Physical Symptoms
• Changes in appetite or weight
• Sleep disturbances, such as insomnia or oversleeping
• Fatigue or lack of energy
• Unexplained physical symptoms, such as headaches or
stomachaches
Cognitive Symptoms
• Difficulty concentrating, remembering details, or making
decisions
• Negative thoughts or distorted thinking patterns
Emotional Symptoms
• Persistent sadness, anxiety, or emptiness
• Feelings of hopelessness or pessimism
• Irritability or restlessness
• Loss of interest in activities or hobbies once enjoyed
Symptoms of Depression
Depression is a mood disorder that affects how a person feels, thinks, and handles daily
activities. The symptoms of depression can vary from person to person and can be
classified as physical, emotional, and cognitive symptoms.

35. Diagnostic Criteria for Major
Depressive Disorder
Overview
Major depressive disorder (MDD) is a mental health
condition characterized by persistent feelings of sadness,
hopelessness, and a lack of interest in activities that were
once enjoyable.
It affects how a person thinks, feels, and behaves, and can
interfere with their ability to function in daily life.
The diagnostic criteria for MDD are outlined in the
Diagnostic and Statistical Manual of Mental Disorders,
Fifth Edition (DSM-5).

36. To be diagnosed with MDD, a person must experience at least 5 of the following
symptoms for a period of 2 weeks or longer, and these symptoms must represent a
change from their previous level of functioning:
•Depressed mood most of the day, nearly every day
•Markedly diminished interest or pleasure in activities that were once enjoyable
•Significant weight loss when not dieting, weight gain, or decrease or increase in appetite
nearly every day
•Insomnia or hypersomnia nearly every day
•Psychomotor agitation or retardation nearly every day
•Fatigue or loss of energy nearly every day
•Feelings of worthlessness or excessive or inappropriate guilt nearly every day
•Diminished ability to think or concentrate, or indecisiveness, nearly every day
•Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide
attempt or a specific plan for committing suicide

37. Diagnostic Criteria for Persistent Depressive Disorder
Diagnostic Criteria
Persistent Depressive Disorder (PDD), formerly known as dysthymia, is a mood disorder characterized
by a depressed mood that persists for at least 2 years. The symptoms of PDD are less severe than those
of Major Depressive Disorder (MDD), but they last longer.
To be diagnosed with PDD, an individual must experience a depressed mood most of the day, for more
days than not, for at least 2 years (1 year for children and adolescents). In addition, the individual
must have at least two of the following symptoms:
• Poor appetite or overeating
• Insomnia or hypersomnia
• Low energy or fatigue
• Low self-esteem
• Poor concentration or difficulty making decisions
• Feelings of hopelessness
The symptoms must cause significant distress or impairment in social, occupational, or other areas of
functioning.

38. Other Depressive Disorders
Disruptive Mood Dysregulation Disorder (DMDD)
DMDD is a relatively new disorder that is
characterized by severe and recurrent temper
outbursts that are grossly out of proportion to
the situation. These outbursts must occur three
or more times per week, and the mood
between outbursts must be persistently irritable
or angry for at least 12 months.

39. Premenstrual Dysphoric Disorder
(PMDD)
PMDD is a severe form of premenstrual syndrome
(PMS) that affects a small percentage of women.
Symptoms include severe mood swings, irritability,
anxiety, depression, and physical symptoms such as
bloating and breast tenderness. Symptoms must occur
during the last week of the menstrual cycle and resolve
within a few days after the onset of menstruation.

40. Substance/Medication-Induced Depressive Disorder
This type of depression is caused by the
use of alcohol, drugs, or certain
medications. Symptoms may occur during
use, withdrawal, or after cessation of use.
The depressive symptoms are not better
explained by a primary depressive disorder.

41. Ms. S.W. is a 48-year-old white female who presented to an outpatient community mental health
agency for evaluation of her symptoms. Over the past eight weeks she has experienced sad mood
every day, which she describes as a feeling of hopelessness and emptiness. She also noticed other
changes about herself, including decreased appetite, insomnia, fatigue, and poor ability to
concentrate. The things that used to bring Ms. S.W. joy, such as gardening and listening to
podcasts, are no longer bringing her the same happiness they used to. She became especially
concerned as within the past two weeks she also started experiencing feelings of worthlessness,
the perception that she is a burden to others, and fleeting thoughts of death/suicide.

42. Sara is 43 years old and she has a son. Last week she came to visit a therapist with the complaints
of worrisome thoughts, difficulty in making decisions, restlessness, headache, sadness, fatigue,
guilt, helplessness and lack of concentration. She experienced these symptoms for the last last
three years.

43. Bella’s mother sought treatment for her daughter due to increasing disruptive behaviors over the past
year, including non-compliance at home and at school, physical aggression toward peers, and frequent
behavioral meltdowns which resembled the temper tantrums of a much younger child. Tantrums
included screaming, yelling, slamming doors, and crying. Triggers could include being asked to take
her daily medication or feeling that someone was standing too close to her.

44. Dave is a 41-year-old male who was referred by his primary care physician after presenting to the ER
with difficulty breathing. Dave’s physician was unable to find a medical explanation for his symptoms,
which left Dave feeling confused, stressed, and angry. Over the last 6 months, Dave has had several
instances where he felt an intense fear that would reach a peak within a few minutes. During these
instances, he would also experience sweating, heart palpitations, chest pain and discomfort, and
shortness of breath. At times, Dave worried that might die. As a result, Dave has persistent worry about
having another attack.

45. The patient was a 42-year-old married women, unemployed, with a history of three major depressive
episodes. Over the last two years, the patient had complained of emotional instability, irritability,
anxiety, low self-esteem, overvalued ideas of guilt, insomnia, sweet craving, poor concentration and
difficulties coping with her work. The symptoms tended to recur in a predictable manner every 3 weeks
and had a negative impact on her relationship with her husband.

46. Tini is a female college student aged 24 years old. She comes to the health clinic accompanied by a
friend and complains of several symptoms that she has experienced over the past 4 weeks. She reports:
difficulty falling asleep, feeling tired after waking up in the morning and experiencing headaches+
difficulty staying focused during classes. These symptoms have led to deterioration in her study and
prompted her to seek advice from the doctor.

47. A 24-year-old African-American female who was admitted to the inpatient psychiatric facility after
a suicide attempt. The patient demonstrated what we will describe as heralding symptoms during the
birth of her second child, but her symptoms dramatically worsened one month prior to her admission
with the birth of her third child. The patient presented with anxiety and depressive symptoms,
including decreased energy, disrupted sleep patterns, and emotional lability.

48. A 28 year-old female presents to the clinic with complaints of pain. Patient cannot recall any mechanism
of injury. She reports she has trouble falling asleep at night and is unable to get a good night’s rest. She
often feels "restless" or "on edge", which she associates with not sleeping. She states she constantly
worries about her performance in school, her family, and her mother’s health, who has recently been
diagnosed with Stage IV Small Cell Carcinoma. Patient also states she wakes up at night with throbbing
headaches that last for a couple hours. She feels tense the majority of the day, causing her to feel stiff.
She also has difficulty paying attention in class and finishing her homework.