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PSYO 2220 (6)
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Midterm

exam 3

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Department
Psychology
Course
PSYO 2220
Professor
elen
Semester
Fall

Description
part 3 abnormal  11/12/2013 Dissociative disorder Characterized by severe alterations or detachments in identity, memory or consciousness Variations of normal depersonalization and derealization experiences: Depersonalization: Distortion in perception of reality related to oneself Derealization: Experiences of unreality related to the external world -focus on multiple personality disorder -we all dissociate -experiences on a continuum depersonalization/derealization disorder Clinical description Persistent, recurrent and severe/frightening feelings of unreality and detachment (depersonalization and derealization) Depersonalization: experiences of unreality, detachment, or being an outside observer with respect to one’s thoughts, feelings, sensations, body, or actions Derealization: experiences of unreality or detachment with respect to surroundings Significant impairment Chronic, lifelong course Comorbidity: anxiety and mood disorders Onset: 16 years old Causes: Cognitive deficits Attention Short-term memory Spatial reasoning Correspond with reports of tunnel vision and mind emptiness Ability to absorb new information Treatment Psychological treatments are unstudied Dissociative amnesia Clinical Description An inability to recall important personal information, usually of a traumatic or stressful nature, that is inconsistent with ordinary forgetfulness Localized Failure to recall specific (usually traumatic) events for a specific period of time; most common type of amnesia Selective Ability to recall some, but not all, events occurring for specific period of time; typically associated with traumatic events Generalized Inability to recall anything, including their identity; very rare Dissociative fugue Travel or wandering that may accompany amnesia (generalized amnesia) -Some of kind of trauma related experience- during trauma the person has checked out and the direct experience in terms of conscious experience may have been missed -Difference between localized and selective Localized- something happened to you and not able to remember that particular event, ie in accident and do not remember it These are specifiers for dissociative amnesia (dissociate fugue is no longer a different disorder but is a specifier) Facts and Statistics Dissociative amnesia and fugue usually begin in adulthood Both conditions show rapid onset and dissipation Both conditions are mostly seen in females Causes Little is known, but trauma and stress seem heavily involved Treatment Persons with dissociative amnesia and fugue state usually get better without treatment Most remember what they have forgotten Dissociative identity disorder Clinical Description Amnesia (dissociative amnesia or fugue) Defining feature: dissociation of certain aspects of personality Involves adoption of several new identities or “alters” (2 to 100; Average = 15) Each displays unique characteristics (voice, behaviours) Alters – The different identities Host: the identity that keeps other identities together The host is the main person but there might be another personality that takes over that develops later Switch: transition from one personality to another Defining feature is dissociation of certain aspects of a personality or having other multiple personalities or identities Usually there is at least 2 identities that the person says that they have Not really separate personalities and separate people (this is how the person experiences them) but they are multiple facets of the same person Abilities or knowledge that each alters have Main person is detached from knowing that other alter learns these things before they dissociate Split in consciousness DSM 5 criteria A. Disruption of identity characterized by 2 or more distinct personality states. Identity disruption involves marked discontinuity in sense of self; accompanied by alterations in affect, behaviour, consciousness, memory, perception, cognition, and/or sensory-motor functioning. B. Recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events that are inconsistent with ordinary forgetting C. The symptoms: cause clinically significant distress or impairment in social, occupational, or other important areas of functioning are not attributable to the physiological effects of a substance or medical condition Statistics 1.5% (year)-- other estimates range from 3 - 6% Female : male = 9:1 Onset = childhood High comorbidity rates Anxiety, substance abuse, depression Borderline personality disorder Lifelong, chronic course Frequency of switching seems to decrease with age Prognosis is guarded at best Causes Biological Biological vulnerability is suspected (no definitive genetic links have been found) Brain imaging studies have found some evidence of smaller hippocampal and amygdala volume Severe abuse/trauma history High correlation with DID DID may be natural tendency to escape or dissociate from horrific experiences New research: DID may be extreme subtype of PTSD Highly suggestibility Auto hypnotic model: highly suggestible persons may be able to use dissociation as a defense against extreme trauma Treatment Goals of treatment: Reintegration of identities Identify and neutralize cues/triggers which provoke memories of trauma and/or dissociation and to neutralize them Visualize, re-live, learn to control/cope with traumatic memories (structured, controlled environment) Hypnosis may be helpful, but no evidence exists Medications: may be used, unknown efficacy Little controlled research for any DID treatments Eating disorders DSM-5 Classification: Feeding & Eating Disorders All disorders include disruptions in eating behavior DSM-5 Eating Disorders: Anorexia Nervosa Bulimia Nervosa Binge-Eating Disorder DSM-5 Feeding Disorders Pica eating non food substances at least one month and developmentally inappropriate (can show up in adulthood in pregnancy) Rumination disorder regurgitate their food- at least a month and developmentally inappropriate Avoidant/Restrictive Food Intake Disorder feeding disorder for kids and adults – avoidance for food or lack of interest (not concerned with weight gain) Anorexia Nervosa and Bulimia Nervosa Central characteristic: extreme fear of gaining weight Self-evaluation is unduly influenced by body shape and weight Especially in Bulimia and sometimes in Anorexia (binge-purging type) engage in inappropriate compensatory behaviors Health threatening, potentially fatal Highest mortality rates of all the psychological disorders Unlike other disorders--major sociocultural component Anorexia is much more driven by weight gain, self evaluation and worth is tied into what the body looks like and a distorted image or what she looks like we all do it do a degree Binge-Eating Disorder and Bulimia Nervosa Uncontrolled eating binges of large amounts of food Medial consequences Anorexia Amenorrhea-absence of menstruation some have it some don’t Dry skin Brittle hair and nails Sensitivity to cold temps Lanugo- fine hair all over your body (like new born baby) Cardiovascular problems Electrolyte imbalance Bulimia Salivary gland enlargement Erosion of dental enamel Electrolyte imbalance Kidney failure Cardiac arrhythmia Seizures Intestinal problems Permanent colon damage Stats Anorexia and Bulimia 90-95% female; 5-10% male Anorexia Onset = age 13 to 15 starting to show up earlier Lifetime prevalence = approx. 2%- 4% Bulimia Lifetime prevalence = approx. 1% to 8% Young women= 6-8% Onset = age 16 to 19 Onset (males) = older Employment – models, dancers (ballet), actress, athletes a lot for males Cultural considerations Prevalence of Anorexia and Bulimia Highest rates of eating disorders occur Western, industrialized countries Most severe cases found in young, affluent, white females in competitive environments Recent immigrants to Western cultures Increased eating disorders and obesity Increasing rates Western countries Pacific rim countries/cities Social dimensions of eating disorders Media and Cultural Considerations Being thin = Success, happiness....really? Cultural imperative for thinness translates into dieting Dieting trends Ideal body size standards Perceptions of normal and “fat” Social and gender standards Internal and perceived Social and peer group norms Developmental and gender considerations Differential patterns of physical development in girls and boys seem to interact with cultural influences to create eating disorders. Ideals of femininity and masculinity are extremely difficult for most to achieve Age of onset for anorexia is concurrent with early puberty and associated rapid weight gain Onset usually in adolescence- gaining weight as we grow Anorexia nervosa Clinical Description Persistent energy intake restriction or behaviour that interferes with weight gain Intense fear of obesity and losing control over eating Marked disturbance in body image (self-perceived weight or shape) Specifies (formerly DSM-IV subtypes) Restricting –weight loss through dieting, fasting and/or excessive exercise Binge-eating-purging type ––weight loss through self-induced vomiting, or the misuse of laxatives, diuretics, or enemas Comorbidity OCD, anxiety, depressive, bipolar disorders, suicide, substance abuse DSM 5 criteria A. Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, physical health B. Intense fear of gaining weight or becoming fat, even if underweight C. Disturbance in how one's body weight or shape is experienced, undue influence of body weight or shape on self- evaluation, or persistent lack of recognition of the seriousness of the current low body weight No percentage of being under weight Don’t have your period seize Specifies: Type (Restricting or Binge-eating/purging) and Severity from Mild to Extreme 15-16 severe 16+ extreme 17-18 mild Normal 18.5 – 25 Bulimia Nervosa Clinical Description Binge eating • Intake of an excessive amount of food during a discrete period of time • Uncontrollability Inappropriate compensatory behaviors • Purging: Self-induced vomiting, diuretics, laxatives • Excessive exercise, fasting, diet pills Comorbidity • Most experience 1+ additional mental disorders Depressive, bipolar, anxiety and bipolar disorders, substance abuse – • Excessive quantities 1500 or more rapid and out of control • Usually not fat/obese 10% one or the other pretty average DSM 5 criteria A. Recurrent episodes of binge eating characterized by both of the following: • eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is larger than most people would eat during a similar period of time/circumstances • a sense of lack of control over eating during the episode B. Recurrent inappropriate compensatory behavior in order to prevent weight gain C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months D. Self-evaluation is unduly influenced by body shape and weight E. The disturbance does not occur exclusively during episodes of anorexia nervosa Specifier: Severity from Mild 1-3 times/week to Extreme 14 times/week Binge-eating disorder Clinical Description • Bingeing episodes – Impaired control over eating Rapid eating, eating: large amounts when not hungry and/or until uncomfortably full ; eating alone – due to embarrassment Associated Features • Marked distress regarding binge eating • Not associated with inappropriate compensatory behaviors and does not occur exclusively during the course of bulimia or anorexia Duration: 1 x per week for 3 months Onset: childhood, adolescence or young adulthood DSM 5 criteria A. Recurrent episodes of binge eating characterized by both of the following: • eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time/circumstances • a sense of lack of control over eating during the episode B. Binge-eating episodes associated with 3 or more of: Eating more rapidly than normal Eating until uncomfortably full Eating large amounts when not hungry Eating alone due to embarrassment (how much one is eating) Feeling disgusted with oneself, depressed or very guilty C. Marked distress regarding binge eating D. Occurs on average, 1x per week for 3 months E. Not associated with inappropriate compensatory behaviors and does not occur exclusively during the course of bulimia or anorexia Specifier: Severity from Mild to Extreme Causes of eating disorders Biological Dimensions Heritability studies suggest a genetic component Twin studies have shown significant heritability (9-23%) Higher in anorexia Some evidence that particular symptoms may be partially genetically determined Inherited tendencies: Emotional instability Poor impulse control Anxiety and mood disorders Neurobiological Possible hypothalamus involvement Lower functioning on hypothalamus Serotonin: low activity has been associated with impulsivity and binge-eating (carb craving) Dopamine, cortisol Psychological Dimensions Low sense of personal control Low self-confidence Perfectionistic attitudes Distorted body image Preoccupation with food and appearance Mood intolerance Being thin will lead to being happier etc. Family Influences Characteristics of families with eating disordered child Successful, driven, perfectionistic Overly concerned with appearance Harmony maintained at a costs Enmeshed History of dieting, eating disorders Mothers High levels of conflict being told you have a fat butt, or being told people would date you if you weren’t so fat stressors reduction in eating binge or restriction purge temporary reduction in anxiety Medical and psychological treatments Anorexia Medical Treatment There are none with demonstrated efficacy Psychological Treatment Weight restoration – first and easiest goal to meet Treatment involves education, behavioral, and cognitive interventions build self esteem, value other things about self Work on anxiety and depressing Perfectionism etc. Treatment often involves the family Expectations that need to addressed Interpersonal –focus on family relationships Long-term prognosis for anorexia is poorer than for bulimia Bulimia Medical Treatment Antidepressants can help reduce binging and purging behaviour Antidepressants are not efficacious in the long-term SSRIs (low serotonin levels) Psychological Treatment Cognitive-behavior therapy (CBT) is the treatment of choice Learning to eat, Interpersonal psychotherapy results in long-term gains similar to CBT Binge eating Cognitive-behavior therapy • Similar format to bulimia Interpersonal psychotherapy • As effective as CBT Medications • Prozac - no benefit • Meridia - possible benefits – Weight loss drug Self help programs Support and learning to practice What is normal sexual behavior What is abnormal sexual behavior No sexual arousal Need for sex all of the time Bestiality Incest Pedophilia/necrophilia Cultural differences between what is normal and not normal Gender dysphoria disorder Clinical Description Individuals who experience themselves to be mismatched to their biological gender and their psychological gender- the wrong sex Born female feels like they want to be a male Experience for as long as they can remember Extreme inconsistency as being different Goal is not sexual- it is to live your life the way you want Prevalence = Rare (.002% - .0014%) For adults—ratio of male : female from 1:1 to 6:1 More male to female conversions For adolescence – ratio fairly equal For children – girls tend to be higher in signs of the disorder May not be truly there Around age of 3 they know their gender identity, as we age it becomes more deeper for us – further in adolescence when we become sexually active Found across many countries and cultures Causes are Unclear Treatment of Gender Identity Disorder Psychosocial Treatment: Involves realigning the person’s psychological gender with their biological sex (if desired) Sex-Reassignment Surgery Prerequisites before surgery (1-2 years with hormones then can get the surgery) 1-2 years in opposite sex role Hormone therapy Many happy after the surgery DSM 5 criteria A. Marked incongruence between one’s experienced/ expressed and assigned gender; of at least 6 months duration and includes at least 2 of the following: 1. Marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics. 2. Astrong desire to be rid of one’s primary and/or secondary sex characteristics 3. Astrong desire for the primary and/or secondary sex characteristics of the other gender 4. Astrong desire to be the other gender 5. Astrong desire to be treated as the other gender 6. Astrong conviction that one has the typical feelings and reactions of the other gender B. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning Arousal disorders male hypoactive sexual desire disorder only in males but more males are troubled by not having sexual desire than females are DSM 5 criteria A. Persistently or recurrently deficient (or absent) sexual/erotic thoughts or fantasies and desire for sexual activity B. Symptoms must persist for 6 months or longer C. Symptoms must cause clinically significant distress to the individual D. The dysfunction is not better explained by a nonsexual mental disorder, as a consequence of severe relationship distress or other significant stressors, or a substance or medical condition Male erectile disorder normal after 40, may happen 40% of the time after 60 peer pressure or stressful situations alcohol DSM 5 criteria A. At least one of the following must be experienced on almost all or all (75-100%) occasions of sexual activity: 1. Marked difficulty in obtaining an erection during sexual activity 2. Marked difficulty in maintaining an erection until the completion of sexual activity 3. Marked decrease in erectile rigidity B. Symptoms must persist for 6 months or longer C. Symptoms must cause clinically significant distress to the individual D. The dysfunction is not better explained by a nonsexual mental disorder, as a consequence of severe relationship distress or other significant stressors, or a substance or medical condition (like diabetes) Female sexual arousal disorder DSM 5 criteria A. Lack of, or significantly reduced , sexual interest/arousal. Must include 3 of: 1. Absent/reduced interest in sexual activity 2. Absent/reduced sexual/erotic thoughts or fantasies 3. Absent/reduced sexual excitement/pleasure during sexual activity in almost all sexual encounters 4. Absent/reduced sexual interest/arousal in response to any internal or external sexual/erotic cues 5. Absent/reduced genital or nongenital sensations during sexual activity in almost all or all sexual encounters 6. No/reduced initiation of sexual activity, and typically unreceptive to a partner’s attempts to initiate B. Symptoms have been present for 6 months (minimum) Note: this disorder combines Hypoactive Sexual Desire & Sexual Arousal Disorders Take into consideration and rule out other things that could effect the ability to be aroused (medication, self confidence, stress, relationship, and sexual pain disorder) Orgasmic disorders Female orgasmic disorder DSM 5 criteria A. Presence of either of the following symptoms and experienced on almost all or all (75-100% of the time) occasions of sexual activity, not necessarily partnered: Marked delay in, marked infrequency of, or absence of orgasm Markedly reduced intensity of orgasmic sensations B. Symptoms must persist for 6 months or longer C. Symptoms must cause clinically significant distress to the individual D. The dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress or other significant stressors , or a substance or medical condition, or lack of stimulation ­ can be taught how to get an orgasm ­ 25-40% of women ­ only 50% have normal orgasms ­ painful sex, like vaginal dryness will make it hard to enjoy Delayed ejaculation DSM 5 criteria A. Either of the following symptoms and experienced on almost all or all (75-100%) occasions of partnered sexual activity and without the individual desiring delay: 1. Marked delay in ejaculation 2. Marked infrequency or absence of ejaculation B. Symptoms must persist for 6 months or longer C. Symptoms must cause clinically significant distress to the individual D. The dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress or other significant stressors , or a substance or medical condition - rare, only about 1% of men - not a good definition of what delay is Premature ejaculation DSM 5 criteria A. Apersistent or recurrent pattern of ejaculation occurring during partnered sexual activity within approximately 1 minute following vaginal penetration and before the individual wishes it B. Symptoms must persist for 6 months or longer C. Symptoms must cause clinically significant distress to the individual D. The dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress or other significant stressors , or a substance or medical condition Mild- 30 seconds Moderate -15 – 30 seconds Server - prior to penetration to 15 seconds -likely there is some anxiety to go along with it Sexual pain disorder Dyspareunia Extreme pain during intercourse Vaginismus Outer third of the vagina undergoes involuntary spasms Complaints include feeling of ripping, burning, or tearing during intercourse All sexual pain disorders must rule out a medical condition DSM-5 combines the above disorders into one disorder: Genito-pelvic pain/penetration disorder DSM 5 criteria A. Persistent or recurrent difficulties with one (or more) of the following: 1. Vaginal penetration during intercourse 2. Marked vulvovaginal or pelvic pain during vaginal intercourse 3. Marked fear or anxiety about vulvovaginal or pelvic pain in anticipation of, during, or as a result of vaginal penetration 4. Marked tensing or tightening for the pelvic floor muscles during attempted vaginal penetration B. Symptoms must persist for 6 months or longer C. Symptoms must cause clinically significant distress to the individual D. The dysfunction is not better explained by a nonsexual mental disorder, as a consequence of severe relationship distress or other significant stressors, a substance or medical condition -anxiety can increase the pain Assessing sexual behavior and sexual dysfunction Comprehensive Interview Include a detailed history of sexual behaviour, lifestyle, and associated factors Psychophysiological Evaluation Exposure to erotic material Determine extent and pattern of physiological and subjective sexual arousal Medical Examination Must rule out potential medical causes Causes Biological Contributions Physical disease and medical illness (affecting blood flow) Substance use/abuse Psychological Contributions Performance anxiety Stress Social and Cultural Contributions Erotophobia – Learned negative attitudes about sexuality Negative or traumatic sexual experiences Deterioration of intimate relationships, lack of communication Specifiers General – all the time Specific - Treatment of sexual dysfunction Masters & Johnson’s Psychosocial Intervention Education and elimination of performance anxiety Sensei - No sex at all – cuddle with clothes on, want to take complete pressure off of the person who is feeling some aversion – continue each week gradually - if there is any problems they go back a step Additional Psychosocial Procedures Squeeze technique – Premature ejaculation Apply pressure once the ejaculation is ready to delay it Masturbatory training – Female orgasm disorder Use of vaginal dilators – vaginismus Exposure to erotic material – Low sexual desire Medical Treatment Primarily available for erectile dysfunction Medication Implants and surgery Paraphilic disorders Nature of Paraphilic Disorders Unusual sexual interests, attraction, and arousal Socially inappropriate attraction and arousal to people/objects Multiple paraphilias are common High comorbidity with other disorders Anxiety, mood, and substance abuse disorders Types of Paraphilias Fetishistic and Tranvestic Disorders Voyeuristic and Exhibitionistic Disorders Sexual Sadism and Masochism Pedophilia Paraphilic Disorders Behaviour may cause distress/impairment to the individual or has entailed personal harm, or risk of harm to others - onset usually in adolescence Fetishistic Clinical Description Recurrent and intense sexual arousal from: 1) the use of nonliving objects, and/or 2) a highly specific focus on nongenital body parts, as manifested by fantasies, urges, or behaviors Such behaviours must cause clinically significant distress or impairment in order to warrant a diagnosis Duration: 6 months Common fetishistic items: female undergarments, footwear, rubber articles, leather clothing Fetish objects are not limited to articles of clothing used in cross-dressing Commonly eroticized body parts: feet, toes, hair Transvestic disorder – name change from fetishism to disorder Clinical Description Recurrent and intense sexual arousal from crossdressing, as manifested by fantasies, urges or behaviours Such behaviors must cause clinically significant distress or impairment in order to warrant a diagnosis Diagnosis made only if: Present for 6 months Cross-dressing is almost always accompanied by sexual excitement Individual experiences distress/impairment Majority are male; many are married Occurant and intense Voyeuristic and exhibitionistic disorder Voyeuristic Disorder: Clinical Description Recurrent and intense sexual arousal from observing an unsuspecting individual naked, undressing, or engaging in sexual activity, as manifested by fantasies, urges or behaviors Risk for being caught is necessary for arousal Individual must be at least 18 years of age to receive a diagnosis Exhibitionistic Disorder: Clinical Description Recurrent and intense sexual arousal from exposure of one’s genitals to unsuspecting persons, as manifested by fantasies, urges or behaviors Compulsive, out of control Element of thrill and risk are necessary for sexual arousal Diagnostic notes Diagnosis may only be made if: Sexual urges have been acted upon with a non-consenting person, or must cause clinically significant distress or impairment Duration of 6+ months Clinically significant distress or impairment may or may not be experienced Sexual masochism disorder Clinical Description Recurrent and intense sexual arousal from the act of being humiliated, beaten, bound, or otherwise made to suffer, as manifested by fantasies, urges or behaviors Such behaviors must cause clinically significant distress or impairment in order to warrant a diagnosis Sexual urges, behaviors, or fantasies must cause clinically significant distress or impairment in order to warrant a diagnosis Duration of 6 months Prevalence is unknown Onset: late teens is typical or young adulthood Sexual sadism disorder Clinical Description Recurrent and intense sexual arousal from physical or psychological suffering of another person, as manifested by fantasies, urges or behaviors (sometimes rapists) Sexual urges have been acted upon with a non-consenting person, or must cause clinically significant distress or impairment in order to warrant a diagnosis Duration of 6+ months Clinically significant distress or impairment may or may not be experienced Prevalence: varies from 2-30% (incarcerated for sex offences); for sexually related homicides: 37-75% Antisocial, criminal acts, not about sexual arousal, more about to make someone suffer Pedophilic disorder Clinical Description Recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving sexual activity with a prepubescent child Specifiers: Exclusive or Nonexclusive type Must have acted on child-focused sexual urges, or must cause clinically significant distress or impairment in order to warrant a diagnosis Minimum 16 years of age for diagnosis; at least 5 years older than victim Not typically diagnosed for an older teen in an ongoing sexual relationship with a younger teen Duration of 6 months Prevalence: 3-5% of male population; unknown for females Comorbidity: substance use disorders, mood, anxiety, other Paraphilic and antisocial personality disorders more step parents, but biological parents do as well more hetero sexual men and women- used to be thought only homosexual Causes Low levels of arousal to appropriate stimuli Sexual problems Social deficits –safety feeling Early experiences Inappropriate arousal / fantasy High sex drive Low suppression of urges / drive Reinforcement via orgasm Assessment and Treatment Assessment Assess extent of deviant patterns of sexual arousal, sexual history, social skills and the ability to form relationships Targets are children who are lonely, and not very social Psychosocial Interventions Behavioral, Family/Marital and Group therapy Relapse prevention 12-step programs (SAA) Medications Chemical castration Work by reducing testosterone levels or secretion and therefore, eliminates sexual desire and sexual fantasies Substance related and addictive disorders Use Abuse Addiction Substance-Related Disorders Problems related to the use/abuse of psychoactive substances Psychoactive substances: alter mood and/or behaviour; ingested to become intoxicated/high Substance-Induced Disorders Non- Substance-Related Disorders Gambling Disorder substance related disorders Clinical Description Characterized by: a problematic pattern of recurrent substance use cognitive, behavioral, physiological symptoms changes in brain circuits Diagnosis of Substance-Related Disorder: Set of criterion reflecting pathological pattern of behaviors related to substance use Diagnosis may be applied to all classes of substances with the exception of caffeine Must have 2 of 11 symptoms over 12 month period Specifiers for severity DSM 5 criteria 1. The substance is often taken in larger amounts or over a longer period than intended 2. There is a persistent desire or unsuccessful efforts to cut down or control substance use. 3. Agreat deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects. 4. Craving, or a strong desire or urge to use the substance Social impairment symptoms 5. 5. Failure to fulfill obligations at work, school or home due to substance use 6. Continues use despite persistent or recurrent social or interpersonal problems caused by or exacerbated by substance use 7. Important social, occupation, or recreational activities are given up or reduced because of substance use Risky use symptoms 8. Recurrent substance use in situations in which it is physically hazardous 9. Continued use despite knowledge of physical or psychological problem that is likely to have been caused or exacerbated by the substance Pharmacological symptoms 10. Tolerance, as defined by either of the following: a. Need for markedly increased amounts to achieve intoxication or the desired effect or b. Markedly diminished effect with continued use of the same amount of the substance. 11. Withdrawal, as manifested by either of the following:
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