Psychological Trauma Definitions

Secure Attachments as a Defense Against Trauma

“All people mature and thrive in a social context that has profound effects on how they cope with life’s stresses.  Particularly early in life, the social context plays a critical role in suffering an individual against stressful situations, and in building the psychological and biological capacities to deal with further stresses.  The primary function of parents can be thought of as helping children modulate their arousal by attuned and well-timed provision of playing, feeding, comforting, touching, looking, cleaning, and resting—in short, by teaching them skills that will gradually help them modulate their own arousal.  Secure attachment bonds serve as primary defenses against trauma-induced psychopathology in both children and adults (Finkelhor & Browne, 1984).  In children who have been exposed to severe stressors, the quality of the parental bond is probably the single most important determinant of long-term damage (McFarlane, 1988).”

van der Kolk, Bessel, Alexander C. McFarlane, and Lars Weisaeth, eds.  1996. Traumatic stress: The effects of overwhelming experience on mind, body, and society.  New York and London: Guilford Press. .p. 185

 Affect Dysregulation in Traumatized Individuals

“As children mature, they gradually become less vulnerable to over-stimulation and learn to tolerate higher levels of excitement.  Over time, their need for physical proximity to their primary caregivers to maintain comfort decreases, and children start spending more time playing with their peers and with their fathers (Field, 1985). Secure children learn how to take care of themselves effectively as long as the environment is more or less predictable; simultaneously, they learn how to get help when they are distressed.  In contrast, avoidant children learn how to organize their behavior effectively under ordinary conditions, but they remain unable to communicate or interpret emotional signals.  In other words, they know how to handle cognition, but not affect (Crittenden, 1994

            Cole and Putnam (1992) have proposed that people’s core concepts of themselves are defined to a substantial degree by their capacity to regulate their internal states and by their behavioral responses to external stress.  The lack of development, or loss, of self-regulatory processes in abused children leads to problems with self-definition: (1) disturbances of the sense of self, such as a sense of separateness, loss of autobiographical memories, and disturbances of body image; (2) poorly modulated affect and impulse control, including aggression against self and others; and (3) insecurity in relationships, such as trouble functioning in social settings; they tend either to draw attention to themselves or to withdraw from social interactions.  Thus, they tend to display either angry, threatening, fearless, acting-out behavior or meek, submissive, fearful, incompetent behavior.  Problems in articulating cause and effect make it hard for them to appreciate their own contributions to their problems and set the stage for paranoid attributions.”

van der Kolk, Bessel, Alexander C. McFarlane, and Lars Weisaeth, eds.  1996. Traumatic stress: The effects o overwhelming experience on mind, body, and society.  New York and London: Guilford Press. .p. 187

 Manifestations of the Absence of Self-Regulation

“The lack or loss of self-regulation is possibly the most far-reaching effect of psychological trauma in both children and adults.  The DSM-IV field trials for PTSD clearly demonstrated that the younger the age at which the trauma occurred, and the longer its duration, the more likely people were to have long-term problems with the regulation of anger, anxiety, and sexual impulses (van der Kolk, Roth, Pelcovitz, & Mandel, 1993).  Pitman, Orr, and Shalev (1993) have pointed out that in PTSD, hyperarousal goes well beyond simple conditioning.  The fact that the stimuli that precipitate emergency responses are not conditioned enough and that many triggers not directly related to the traumatic experience may precipitate extreme reactions is merely the beginning of the problem.  Loss/lack of self-regulation may be expressed in many different ways: as a loss of ability to focus on appropriate stimuli; as attentional problems; as an inability to inhibit action when aroused (loss of impulse control); or as uncontrollable feelings of rage, anger, or sadness.  The results of a study by McFarlane, Weber, and Clark (1993) of event-related potentials in people with PTSD illustrate these various effects.”

Van der Kolk, Bessel, Alexander C. McFarlane, and Lars Weisaeth, eds.  1996. Traumatic stress: The effects o overwhelming experience on mind, body, and society.  New York and London: Guilford Press. .p. 187

 Self-Mutilation

 Eating Disorders

 Substance Abuse

 Dissociation

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EMDR-DID-PTSD           (defined)

 EMDR

Eye Movement Desensitization and Reprocessing

"Eye Movement Desensitization and Reprocessing (EMDR)¹ integrates elements of many effective psychotherapies in structured protocols that are designed to maximize treatment effects. These include psychodynamic, cognitive behavioral, interpersonal, experiential, and body-centered therapies². EMDR is an information processing therapy and uses an eight phase approach.

During EMDR¹ the client attends to past and present experiences in brief sequential doses while simultaneously focusing on an external stimulus. Then the client is instructed to let new material become the focus of the next set of dual attention. This sequence of dual attention and personal association is repeated many times in the session.

Eight Phases of Treatment

The first phase is a history taking session during which the therapist assesses the client's readiness for EMDR and develops a treatment plan. Client and therapist identify possible targets for EMDR processing. These include recent distressing events, current situations that elicit emotional disturbance, related historical incidents, and the development of specific skills and behaviors that will be needed by the client in future situations.

During the second phase of treatment, the therapist ensures that the client has adequate methods of handling emotional distress and good coping skills, and that the client is in a relatively stable state. If further stabilization is required, or if additional skills are needed, therapy focuses on providing these. The client is then able to use stress reducing techniques whenever necessary, during or between sessions. However, one goal is not to need these techniques once therapy is complete.

In phase three through six, a target is identified and processed using EMDR procedures. These involve the client identifying the most vivid visual image related to the memory (if available), a negative belief about self, related emotions and body sensations. The client also identifies a preferred positive belief. The validity of the positive belief is rated, as is the intensity of the negative emotions.

After this, the client is instructed to focus on the image, negative thought, and body sensations while simultaneously moving his/her eyes back and forth following the therapist's fingers as they move across his/her field of vision for 20-30 seconds or more, depending upon the need of the client. Athough eye movements are the most commonly used external stimulus, therapists often use auditory tones, tapping, or other types of tactile stimulation. The kind of dual attention and the length of each set is customized to the need of the client. The client is instructed to just notice whatever happens. After this, the clinician instructs the client to let his/her mind go blank and to notice whatever thought, feeling, image, memory, or sensation comes to mind. Depending upon the client's report the clinician will facilitate the next focus of attention. In most cases a client-directed association process is encouraged. This is repeated numerous times throughout the session. If the client becomes distressed or has difficulty with the process, the therapist follows established procedures to help the client resume processing. When the client reports no distress related to the targeted memory, the clinician asks him/her to think of the preferred positive belief that was identified at the beginning of the session, or a better one if it has emerged, and to focus on the incident, while simultaneously engaging in the eye movements. After several sets, clients generally report increased confidence in this positive belief. The therapist checks with the client regarding body sensations. If there are negative sensations, these are processed as above. If there are positive sensations, they are further enhanced.

In phase seven, closure, the therapist asks the client to keep a journal during the week to document any related material that may arise and reminds the client of the self-calming activities that were mastered in phase two.

The next session begins with phase eight, re-evaluation of the previous work, and of progress since the previous session. EMDR treatment ensures processing of all related historical events, current incidents that elicit distress, and future scenarios that will require different responses. The overall goal is produce the most comprehensive and profound treatment effects in the shortest period of time, while simultaneously maintaining a stable client within a balanced system.

After EMDR processing, clients generally report that the emotional distress related to the memory has been eliminated, or greatly decreased, and that they have gained important cognitive insights. Importantly, these emotional and cognitive changes usually result in spontaneous behavioral and personal change, which are further enhanced with standard EMDR procedures." www.emdr.com

¹Shapiro, F. (2001). Eye Movement Desensitization and Reprocessing: Basic Principles, Protocols and Procedures (2nd ed.). New York: Guilford Press.

²Shapiro, F. (2002). EMDR as an Integrative Psychotherapy Approach: Experts of Diverse Orientations Explore the Paradigm Prism. Washington, DC: American Psychological Association Books.

Posttraumatic Stress Disorder (PTSD)

"The essential feature of Posttraumatic Stress Disorder us the development of characteristic symptoms following exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one's physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate (Criteria A1).  The person's response to the event must involve intense fear, helplessness, or horror (or in children, the response must involve disorganized or agitated behavior) (Criterion A2).  The characteristic symptoms resulting from the exposure to the extreme trauma include persistent reexperiencing of the traumatic event (Criterion E), and the disturbance must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion F).

Traumatic events that are experienced directly include, but are not limited to, military combat, violent personal assault (sexual assault, physical attack, robbery, mugging), being kidnapped, being taken hostage, terrorist attack, torture, incarceration as a prisoner of war or in a concentration camp, natural or manmade disasters, severe automobile accidents, or being diagnosed with a life-threatening illness.  For children, sexually traumatic events may include developmentally inappropriate sexual experiences without threatened or actual violence or injury.  Witnessed events include, but are not limited to, observing the serious injury or unnatural death of another person due to violent assault, accident, war, or disaster or unexpectedly witnessing a dead body or body parts.  Events experienced by others that are learned about include, but are not limited to, violent personal assault, serious accident, or serious injury experienced y a family member or a close friend; learning about the sudden, unexpected death of a family member or a close friend; or learning that one's child has a life threatening disease.  The disorder may be especially sever or long lasting when the stressor is of human design (e.g., torture, rape). the likelihood of developing this disorder may increase as the intensity of and physical proximity to the stressor increase.

The traumatic event can be reexperienced in various ways.  Commonly the person has recurrent and intrusive recollections of the event (Criterion B1) or recurrent distressing dreams during which the event can be replayed or otherwise represented (Criterion B2). In rare instances, the person experiences dissociative states that last from a few seconds to several hours, or even days, during which components of the event are relived and the person behaves as though experiencing the event at that moment (Criterion B3).  These episodes, often referred to as "flashbacks," are typically brief but can be associated with prolonged distress and heightened arousal.  Intense psychological distress (Criterion B4) or physiological reactivity (Criterion B5) often occurs when the person is exposed to triggering events that resemble or symbolize an aspect of the traumatic event (e.g., anniversaries of the traumatic event; cold, snowy weather or uniformed guards for survivors of death camps in cold climates; hot, humid weather for combat veterans of the South Pacific; entering any elevator for an woman who was reaped in an elevator).

Stimuli associated with the trauma are persistently avoided.  The person commonly makes deliberate efforts to avoid thoughts, feelings, or conversations about the traumatic event (Criterion C1) and to avoid activities, situations, or people who around recollections of it (Criterion C2).  This avoidance of reminders may include amnesia for an important aspect of the traumatic event (Criterion C3).  Diminished responsiveness to the external work, referred to as "psychic numbing" or "emotional anesthesia," usually begins soon after the traumatic event.  The individual may complain of having markedly diminished interest or participation in previously enjoyed activities (Criterion C4), of feeling detached or estranged from other people (Criterion C5), or of having markedly reduced ability to feel emotions (especially those associated with intimacy, tenderness and sexuality) (Criterion C6).  The individual may have a sense of a foreshortened future (e.g., not expecting to have a career, marriage, children, or a normal life span) (Criterion C7).

The individual has persistent symptoms of anxiety or increased arousal that were not present before the trauma.  these symptoms may include difficulty falling or staying asleep that may be to recurrent nightmares during which the traumatic event is relived (Criterion D1), hypervigilance (Criterion D4), and exaggerated startle response (Criterion D5).  Some individuals report irritability or outburst of anger (Criterion D2) or difficulty concentrating or completing tasks (Criterion D3)."

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Dissociative Identity Disorder (DID)

"The essential feature of Dissociative identity Disorder is the presence of two or more distinct identities or personality states (Criterion A) that recurrently take control of behavior (Criterion B).  There is an inability to recall important personal information, the extent of which is too great to be explained by ordinary forgetfulness (Criterion C).  The disturbance is not due tot eh direct physiological effects of a substance or a general medical condition (Condition D.).  In children, the symptoms cannot be attributed to imaginary playmates or other fantasy play.

Dissociative Identity Disorder reflects a failure to integrate various aspects of identity, memory, and consciousness.  Each personality state may be experienced as if it has a distinct personal history, self-image, and identity, including a separate name.  Usually there is a primary identity that carries the individual's given name and is passive, dependent, guilty, and depressed.  The alternate identities frequently have different names and characteristics that contrast with the primary identity (e.g., are hostile, controlling, and self-destructive).  Particular identities may emerge in specific circumstances and may differ in reported age and gender, vocabulary, general knowledge, or predominant affect.  Alternate identities are experienced as taking control in sequence, ore at the expense of the other, and may deny knowledge of one another, be critical of one another, or appear to be in open conflict.  Occasionally, one or more powerful identities allocate time to the others.  Aggressive or hostile identities may at times interrupt activities or place the others in uncomfortable situations.

Individuals with this disorder experience frequent gaps in memory for personal history, both remote and recent.  The amnesia is frequently asymmetrical.  The more passive identities tend to have more constricted memories, whereas the more hostile, controlling, or "protector" identities have more complete memories.  An identity that is not in control may nonetheless gain access to consciousness by producing auditory or visual hallucinations (e.g., a voice giving instructions).  Evidence of amnesia may be uncovered by reports from others who have witnessed behavior that is disavowed by the individual or by the individual's own discoveries (e.g., finding items of clothing at home that the individual cannot remember having bought).  There may be loss of memory not only for recurrent periods of time, but also an overall loss of biographical memory for some extended period of childhood, adolescence, or even adulthood.  Transitions among identities are often triggered by psychosocial stress.  The time required to switch from one identity to another is usually a matter of seconds, but, less frequently, may b gradual.  Behavior that may be frequently associated with identity switches include rapid blinking, facial changes, changes in voice or demeanor, or disruption in the individual's train of thoughts.  The number of identities reported ranges from 2 to more than 100.  Half of reported cases include the individuals with 10 or fewer identities."

Diagnostic and Statistical Manual of Mental Disorders. 2000.  4th ed. Washington, D.C.: American Psychiatric Association.

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Substance Abuse

Features

“The essential feature of Substance Abuse is a maladaptive pattern of substance use manifested by recurrent and significant adverse consequences related to the repeated use of substances.  In order for an Abuse criterion to be met, the substance-related problem must have occurred repeatedly during the same 12-month period or been persistent.  There may be repeated failure to fulfill major role obligations, repeated use in situations in which it is physically hazardous, multiple legal problems, and recurrent social and interpersonal problems (Criterion A).  Unlike the criteria for Substance Dependence, the criteria for Substance Abuse do not include only the harmful consequences of repeated use.  A diagnosis of Substance Abuse is preempted by the diagnosis of Substance Dependence if the individual’s pattern of substance use has ever met the criteria for Dependence for that class of substances (Criterion B).  Although a diagnosis of Substance Abuse is more likely in individuals who have only recently started taking the substance, some individuals continue to have substance-related adverse social consequences over a long period of time without developing evidence of Substance Dependence.  The category of Substance Abuse does not apply to caffeine and nicotine.  The term abuse should be applied only to a pattern of substance use that meets the criteria for this disorder; the term should not be used as a synonym for “use”,” misuse,” or “hazardous use.”

The individual may repeatedly demonstrate intoxication or other substance-related symptoms when expected to fulfill major role obligations at work, school, or home (Criterion A1).  There may be repeated absences or poor work performance related to recurrent hangovers.  A student might have substance-related absences, suspensions, or expulsions from school.  While intoxicated, the individual may neglect children or household duties.  The person may repeatedly be intoxicated in situations that are physically hazardous (.e.g., while driving a car, operating machinery, or engaging in risky recreational behavior such as swimming or rock climbing) (Criterion A2). There may be recurrent substance-related legal problems (e.g., arrests for disorderly conduct, assault and battery, driving under the influence) (Criterion A3).  The person may continue to use the substance despite a history of undesirable persistent or recurrent social or interpersonal consequences (e.g., marital difficulties or divorce, verbal or physical fights) (Criterion A4).

Criteria for Substance Abuse

A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifestd by one (or More) of the following, occurring within a 12-month period:

(1) Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household)

(2) Recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)

(3) Recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct)

(4) Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., personal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights)

B. The symptoms have never met the criteria for Substance Dependence for this class of substance.” (p. 198-199)

American Psychiatric Association. 2000. Diagnostic and statistical manual of mental disorders. 4^th ed. Washington, D.C.: American Psychiatric Association.

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Dissociative Identity Disorder (DID)

"The essential feature of Dissociative identity Disorder is the presence of two or more distinct identities or personality states (Criterion A) that recurrently take control of behavior (Criterion B).  There is an inability to recall important personal information, the extent of which is too great to be explained by ordinary forgetfulness (Criterion C).  The disturbance is not due tot eh direct physiological effects of a substance or a general medical condition (Condition D.).  In children, the symptoms cannot be attributed to imaginary playmates or other fantasy play.

Dissociative Identity Disorder reflects a failure to integrate various aspects of identity, memory, and consciousness.  Each personality state may be experienced as if it has a distinct personal history, self-image, and identity, including a separate name.  Usually there is a primary identity that carries the individual's given name and is passive, dependent, guilty, and depressed.  The alternate identities frequently have different names and characteristics that contrast with the primary identity (e.g., are hostile, controlling, and self-destructive).  Particular identities may emerge in specific circumstances and may differ in reported age and gender, vocabulary, general knowledge, or predominant affect.  Alternate identities are experienced as taking control in sequence, ore at the expense of the other, and may deny knowledge of one another, be critical of one another, or appear to be in open conflict.  Occasionally, one or more powerful identities allocate time to the others.  Aggressive or hostile identities may at times interrupt activities or place the others in uncomfortable situations.

Individuals with this disorder experience frequent gaps in memory for personal history, both remote and recent.  The amnesia is frequently asymmetrical.  The more passive identities tend to have more constricted memories, whereas the more hostile, controlling, or "protector" identities have more complete memories.  An identity that is not in control may nonetheless gain access to consciousness by producing auditory or visual hallucinations (e.g., a voice giving instructions).  Evidence of amnesia may be uncovered by reports from others who have witnessed behavior that is disavowed by the individual or by the individual's own discoveries (e.g., finding items of clothing at home that the individual cannot remember having bought).  There may be loss of memory not only for recurrent periods of time, but also an overall loss of biographical memory for some extended period of childhood, adolescence, or even adulthood.  Transitions among identities are often triggered by psychosocial stress.  The time required to switch from one identity to another is usually a matter of seconds, but, less frequently, may b gradual.  Behavior that may be frequently associated with identity switches include rapid blinking, facial changes, changes in voice or demeanor, or disruption in the individual's train of thoughts.  The number of identities reported ranges from 2 to more than 100.  Half of reported cases include the individuals with 10 or fewer identities."

Diagnostic and Statistical Manual of Mental Disorders. 2000.  4th ed. Washington, D.C.: American Psychiatric Association.

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Eating Disorders

 “The Eating Disorders are characterized by severe disturbances in eating behavior.  This section includes two specific diagnoses, Anorexia Nervosa and Bulimia Nervosa.  Anorexia Nervosa is characterized by a refusal to maintain a minimally normal body weight.  Bulimia Nervosa is characterized by repeated episodes of binge eating followed by inappropriate compensatory behaviors such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise.  A disturbance in perception of body shape and weight is an essential feature of both Anorexia Nervosa and Bulimia Nervosa.  An Eating Disorder Not Otherwise Specified category is also provided for coding behaviors that do not meet criteria for a specific Eating Disorder.

Simple obesity is include in the International Classification of Diseases (ICD) as a general medical condition but does not appear in DSM-IV because it has not been established that it is consistently associated with a psychological or behavioral syndrome.  However, when there is evidence that psychological factors are of importance in the etiology or course of a particular case of obesity, this can be indicated by noting the presence of Psychological Factors Affecting Medical Condition.

Disorders of Feeding and Eating that are usually first diagnosed in infancy or early childhood (i.e., Pica, Rumination Disorder, and Feeding Disorder of Infancy or Early Childhood) are included in the section “Feeding and Eating Disorders of Infancy or Early Childhood.

 Anorexia Nervosa

 Diagnostic Features

The essential features of Anorexia Nervosa are that the individual refuses to maintain a minimally normal body weight, is intensely afraid of gaining weight, and exhibits a significant disturbance in the perception of the shape or size of his or her body.  In addition, postmenarcheal females with this disorder are amenorrheic.  (The term anorexia is a misnomer because loss of appetite is rare.)

The individual maintains a body weight that is below a minimally normal level for age and height (Criterion A).  When Anorexia Nervosa develops in an individual during childhood or early adolescence, there may be failure to make expected weight gains (i.e., while growing in height) instead of weight loss.

Criterion A provides a guideline for determining when the individual meets the threshold for being underweight.  It suggests that the individual weigh less than 85% of that weight that is considered normal for that person’s age and height (usually computed using one of several published versions of the Metropolitan Life Insurance tables or pediatric growth charts.).  An alternative and somewhat stricter guideline (used in the ICD-10 Diagnostic Criteria for research) requires that the individual have a body mass index (BMI) (calculated as weight in kilograms/height in meters2) equal to or below 17.5kg/m2.  These cutoffs are provided only as suggested guidelines for eh clinician, since it is unreasonable to specify a single standard for minimally normal weight that applies to all individuals of a given age and height.  In determining a minimally normal weight, the clinician should consider not only such guidelines but also the individual’s body build and weight history.

Usually weight loss is accomplished primarily through reduction in total food intake.  Although individuals may begin by excluding from their diet what they perceive to be highly caloric foods, most eventually end up with a very restricted diet that is sometimes limited to only a few foods.  Additional methods of weight loss include purging (i.e., self-induced vomiting or the misuse of laxative or diuretics) and increased or excessive exercise.)

Individuals with this disorder intensely fear gaining weight or becoming fat (Criterion B).  This intense fear of becoming fat is usually not alleviated by the weight loss.  In fact, concern about weight gain often increases even as actual weight continues to decrease.

The experience and significance of body weight and shape are distorted in these individuals (Criterion C).  Some individuals feel globally overweight.  Others realize that they are thin but are still concerned that certain parts of their bodies, particularly the abdomen, buttocks, and thighs are “to fat.”  They may employ a wide variety of techniques to estimate their body size and weight, including excessive weighing, obsessive measuring of body parts, and persistently using a mirror to check for perceived areas of “fat.”  The self-esteem of individuals with Anorexia Nervosa is highly dependent on their body shape and weight.  Weight loss is viewed as an impressive achievement and a sign of extraordinary self-discipline, whereas weight gain is perceived as an unacceptable failure of self-control.  Though some individuals with this disorder may acknowledge being thin, they typically deny the serious medical implications of their malnourished state.

In postmenarcheal females, amenorrhea (due to abnormally low levels of estrogen secretion that are due in turn to diminished pituitary secretion of follicle-stimulating hormone [PSH] and luteinizing hormone [LH]) is an indicator of physiological dysfunction in Anorexia Nervosa (Criterion D.)  Amenorrhea is usually a consequence of the weight loss but, in a minority of individuals, may actually precede it.  In prepubertal females, menarche may be delayed by the illness.

The individual is often brought to professional attention by family members after marked weight loss (or failure to make expected weight gains) has occurred.  If individuals seek help on their own, it is usually because of their subjective distress over the somatic and psychological sequelae of starvation.  It is rare for an individual with Anorexia Nervosa to complain of weight loss per se.  Individuals with Anorexia Nervosa frequently lack insight into, or have considerable denial of, the problem and may be unreliable historians.  It is therefore often necessary to obtain information form parents or other outside sources to evaluate the degree of weight loss and other features of the illness.”  p. 583-584.

 Bulimia Nervosa

 “Diagnostic Features

The essential features of Bulimia Nervosa are binge eating and inappropriate compensatory methods to prevent weight gain.  In addition, the self-evaluation of individuals with Bulimia Nervosa is excessively influenced by body shape and weight.  To qualify for the diagnosis, the binge eating and the inappropriate compensatory behaviors must occur, on average, at least twice a week for 3 months (Criterion C.)

A binge is defined as eating in a discrete period of time an amount of food that is definitely larger than most individuals would eat under similar circumstances (Criterion A1.).  The clinician should consider the context in which the eating occurred—what would be regarded as excessive consumption at a typical meal might be considered normal during a celebration or holiday meal.  A “discrete period of time” refers to a limited period, usually less than 2 hours.  A single episode of binge eating need not be restricted to one setting.  For example, an individual may begin a binge in a restaurant and then continue it on returning home.  Continual snacking on small amounts of food throughout the day would not be considered a binge.

Although the type of food consumed during the binge varies, it typically includes sweet, high-calorie foods such as ice cream or cake.  However, binge eating appears to be characterized more by an abnormality in the amount of food consumed than by a craving for a specific nutrient, such as carbohydrate.  Although individuals with Bulimia Nervosa consume more calories during an episode of binge eating than persons without Bulimia Nervosa consume during a meal, the fractions of calories derived from protein, fat, and carbohydrate are similar.

Individuals with Bulimia Nervosa are typically ashamed of their eating problems and attempt to conceal their symptoms.  Binge eating usually occurs in secrecy, or as inconspicuously as possible.  An episode may or may not be planned in advance and is usually (but not always) characterized by rapid consumption.  The binge eating often continues until the individual is uncomfortably, or even painfully, full.  Binge eating is typically triggered by dysphoric mood states, interpersonal stressors intense hunger following dietary restraint, or feelings related to body weight, body shape, and food.  Binge eating may transiently reduce dysphoria, but disparaging self-criticism and depressed mood often follow.

An episode of binge eating is also accompanied by a sense of lack of control (Criterion A2).  An individual may be in a frenzied state while binge eating, especially early in the course of the disorder.  Some individuals describe a dissociative quality during, or following, the binge episodes.  After Bulimia Nervosa has persisted for some time, individuals may report that their binge-eating episodes are no longer characterized by an acute feeling of loss of control, but rather by behavioral indicators of impaired control, such as difficulty resisting binge eating or difficulty stopping a binge once it has begun.  The impairment in control associated with binge eating in bulimia Nervosa is not absolute; for example, an individual may continue binge eating while the telephone is ringing, but will cease if a roommate or spouse unexpectedly enters the room.

Another essential feature of Bulimia Nervosa is the recurrent use of inappropriate compensatory behaviors to prevent weight gain (Criterion B).  Many individuals with Bulimia Nervosa employ several methods in their attempt to compensate for binge eating.  The most common compensatory technique is the induction of vomiting after an episode of binge eating.  This method of purging is employed by 80%-90% of individuals with Bulimia Nervosa who present for treatment of eating disorders clinics.  The immediate effects of vomiting include relief from physical discomfort and reduction of fear of gaining weight.  In some cases, vomiting becomes a goal in itself, and the person will binge in order to vomit or will vomit after eating a small amount of food.  Individuals with Bulimia Nervosa may use a variety of methods to induce vomiting, including the use of fingers or instruments to stimulate the gag reflex.  Individuals generally become adept at inducing vomiting and are eventually able to vomit at will.  Rarely, individuals consume syrup of ipecac to induce vomiting.  Other purging behaviors include the issue of laxatives and diuretics.  Approximately one-third of those with Bulimia Nervosa misuse laxatives after binge eating.  Rarely, individuals with the disorder will misuse enemas following episodes of binge eating, but this is seldom the sole compensatory method employed.

Individuals with Bulimia Nervosa may fast for a day or more or exercise excessively in an attempt to compensate for binge eating.  Exercise may be considered to be excessive when it significantly interferes with important activities, when it occurs at inappropriate times or in inappropriate settings, or when the individual continues to exercise despite injury or other medical complications.  Rarely, individuals with this disorder may take thyroid hormone in an attempt to avoid weight gain.  Individuals with diabetes mellitus and Bulimia Nervosa may omit or reduce insulin doses in order to reduce the metabolism of food consumed during eating binges.

Individuals with Bulimia Nervosa place an excessive emphasis on body shape and weight in their self-evaluation, and these factors are typically the most important ones in determining self-esteem (Criterion D).  Individuals with this disorder may closely resemble those with Anorexia Nervosa in their fear of gaining weight, in their desire to lose weight, and in the level of dissatisfaction with their bodies.  However, a diagnosis of Bulimia Nervosa should not be given when the disturbance occurs only during episodes of Anorexia Nervosa (Criterion E).”  p. 589-591

 Diagnostic and statistical manual of mental disorders. 2000. 4^th ed. Washington, D.C.: American Psychiatric Association.

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Major Depressive Disorder

 “Diagnostic Features

The essential feature of Major Depressive Disorder is a clinical course that is characterized by one or more Major Depressive Episodes without a history of Manic, Mixed, or Hypomanic Episodes (Criteria A and C).  Episodes of Substance-Induced Mood Disorder (due to the direct physiological effects of a drug of abuse, a medication, or toxin exposure) or of Mood Disorder Due to a General Medical Condition do not count toward a diagnosis of Major Depressive Disorder.  In addition, the episodes must not be better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified (Criterion B).

            The fourth digit in the diagnostic code for Major Depressive Disorder indicates whether it is a Single Episode (used only for first episodes) or Recurrent.  It is sometimes difficult to distinguish between a single episode with waxing and waning symptoms and two separate episodes.  For purposes of this manual, an episode is considered to have ended when the full criteria for eh Major Depressive Episode have not been met for at least 2 consecutive months.  During this 2-month period, there is either complete resolution of symptoms or the presence of depressive symptoms that no longer meet the full criteria for a Major Depressive Episode (In Partial Remission).

            The fifth digit in the diagnostic code for Major Depressive Disorder indicates the current state of the disturbance.  If the criteria for a Major Depressive Disorder are met, the severity of the episode is notes as Mild, Moderate, Severe Without Psychotic Features, or Severe With Psychotic Features.  If the criteria for a Major Depressive Episode are not currently met, the fifth digit is used to indicate whether the disorder is In Partial Remission or In Full Remission.

            If Manic, Mixed, or Hypomanic Episodes develop in the course of Major Depressive Disorder, the diagnosis is changed to a Bipolar Disorder.  However, if manic or hypomanic symptoms occur as a direct effect of antidepressant treatment, use of other medications, substance use, or toxin exposure, the diagnosis of Major Depressive Disorder remains appropriate and an addition diagnosis of Substance-induced Mood Disorder, With Manic features (or With Mixed Features), should be noted.  Similarly, if manic or hypomanic symptoms occur as a direct effect of a general medical condition, the diagnosis of Major Depressive Disorder remains appropriate and an additional diagnosis of Mood Disorder Due to a General Medical Condition, With Manic Features (or With Mixed Features), should be noted.” p. 369

 “Course

Major Depressive Disorder may begin at any age, with an average age at onset in the mid-20s.  Epidemiological data suggest that the age at onset is decreasing for those born more recently.  The course of Major Depressive Disorder, Recurrent, is variable.  Some people have isolated episodes that are separated by many years without any depressive symptoms, whereas others have clusters of episodes, and still others have increasingly frequent episodes as they grow older.  Some evidence suggests that the periods of remission generally last longer early in the course of the disorder.  The number of prior episodes predicts the likelihood of developing a subsequent Major Depressive Episode.  At least 60% of individuals with Major Depresssive Disorder, Single Episode, can be expected to have a second episode.  Individuals who have had tow episodes have a 70% chance of having a third, and individuals who have had three episodes have a 90% chance  of having a fourth.  About 5%-10% of individuals with Major Depressive Disorder, single Episode, subsequently develop a Manic Episode (i.e., develop Bipolar I Disorder).

            Major Depressive Episodes may end completely (in about two-thirds of cases), or only partially or not at all (in about one-third of cases).  For individuals who have only partial remission, there is a greater likelihood of developing additional episodes and of continuing the pattern of partial interepisode recovery.  The longitudinal course specifiers With Full Interepisode Recovery and Without Full Interepisode Recovery may therefore have prognostic value.  A number of individuals have pre-existing Dysthymic Disorder prior to the onset of Major Depressive Disorder, single Episode.  Some evidence suggests that these individuals are more likely to have additional Major Depressive Episodes, have poorer interepisode recovery, and may require additional acute-phase treatment and a longer period of continuing treatment to attain and maintain a more thorough and longer-lasting euthymic state.

            Follow-up naturalistic studies suggested that 1 year after the diagnosis of a major Depressive Episode, 40% of individuals still have symptoms that are sufficiently severe to meet criteria for a full Major Depressive Episode, roughly 20% continue to have some symptoms that no longer meet full criteria for a Major Depressive Episode (i.e., major Depressive Disorder, In Partial Remission), and 40% have no Mood Disorder.  The severity of the initial Major Depressive Episode appears to predict persistence.  Chronic general medical conditions are also a risk factor for more persistent episodes.

            Episodes of Major Depressive Disorder often follow a severe psychosocial stressor, such as the death of a loved one or divorce.  Studies suggest that psychosocial events 9stressors) may play a more significant role in the precipitation of the first or second episodes of Major Depressive Disorder and may play less of a role in the onset of subsequent episodes.  Chronic general medical conditions and Substance Dependence (particularly Alcohol or Cocaine Dependence) may contribute to the onset or exacerbation of Major Depressive Disorder.

            It is difficult to predict whether the first episode of a Major Depressive Disorder in a young person will ultimately evolve into a Bipolar Disorder.  Some data suggest that the acute onset of severe depression, especially with psychotic features and psychomotor retardation, in a young person without prepubertal psychopathology is more likely to predict a bipolar disorder.  A family history of Bipolar Disorder may also be suggestive of subsequent development of Bipolar Disorder.” p. 372-373

 Diagnostic and statistical manual of mental disorders. 2000. 4^th ed.  Washington, D.C.: American Psychiatric Association.

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Anxiety Disorders

“The following disorders are contained in this section:  Panic Disorder Without Agoraphobia, Panic Disorder with Agoraphobia, Agoraphobia Without History of panic Disorder, Specific Phobia, Social Phobia, Obsessive-Compulsive Disorder, Posttraumatic Stress Disorder, Acute Stress Disorder, Generalized Anxiety Disorder, Anxiety Disorder Due to a General Medical Condition, Substance-Induced Anxiety Disorder, and Anxiety disorder Not Otherwise Specified.  Because Panic Attacks and Agoraphobia occur in the context of several of these disorders, criteria sets for a Panic Attack and for Agoraphobia are listed separately at the beginning of this section.

A Panic Attack is a discrete period in which there is the sudden onset of intense apprehension, feafulness, or terror, often associated with feelings of impending doom.  During these attacks, symptoms such as shortness of breath, palpitations, chest pain or discomfort, choking or smothering sensations, and fear of “going crazy” or losing control are present.

Agoraphobia is anxiety about, or avoidance of, places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having a Panic Attack or panic-like symptoms.

Panic Disorder Without Agoraphobia is characterized by recurrent unexpected Panic Attacks about which there is persistent concern.  Panic Disorder With Agoraphobia is characterized by both recurrent unexpected Panic Attacks and Agoraphobia.

Agoraphobia Without History of Panic Disorder is characterized by the presence of Agoraphobia and panic-like symptoms without a history of unexpected Panic Attacks.

Specific Phobia is characterized by clinically significant anxiety provoked by exposure to a specific feared object or situation, often leading to avoidance behavior.

Social Phobia is characterized by clinically significant anxiety provoked by exposure to certain types of social or performance situations, often leading to avoidance behavior.

Obsessive-Compulsive Disorder is characterized by obsessions (which cause marked anxiety or distress) and/or compulsions (which serve to neutralize anxiety).

Posttraumatic Stress Disorder is characterized by the reexperiencing of an extremely traumatic event accompanied by symptoms of increased arousal and by avoidance of stimuli associated with the trauma.

Acute Stress Disorder is characterized by symptoms similar to those of Posttraumatic Stress Disorder that occur immediately in the aftermath of an extremely traumatic event.

Generalized Anxiety Disorder is characterized by at least 6 months of persistent and excessive anxiety and worry.

Anxiety Disorder Due to a General Medical Condition is characterized by prominent symptoms of anxiety that are judged to be a direct physiological consequence of a general medical condition.

Substance-Induced Anxiety Disorder is characterized by prominent symptoms of anxiety that are judged to be a direct physiological consequence of a drug of abuse, a medication, or toxin exposure.

Anxiety Disorder Not Otherwise Specified is included for coding disorders with prominent anxiety or phobic avoidance that do not meet criteria for any of the specific Anxiety Disorders defined in this section (or anxiety symptoms about which there is inadequate or contradictory information.)

Because Separation Anxiety Disorder (characterized by anxiety related to separation from parental figures) usually develops in childhood, it is included in the “Disorders usually first diagnosed in Infancy, Childhood, or Adolescence section.  Phobic avoidance that is limited to genital sexual contact with a sexual partner is classified as Sexual Aversion Disorder and is included in the “Sexual and Gender Identity Disorders” section.” p. 429-430

 For more information about specific anxiety disorders, consult the Diagnostic and Statistical Manual of Mental Disorders. 2000. 4^th ed. Washington, D.C.: American Psychiatric Association. p. 430-484.

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Borderline Personality Disorder

 Diagnostic Features

“The essential features of Borderline Personality Disorder is a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity that begins by early adulthood and is present in a variety of contexts.

            Individuals with Borderline personality Disorder make frantic efforts to avoid real or imagined abandonment (Criterion 1).  The perception of impending separation or rejection, or the loss of external structure, can lead to profound changes in self-image, affect, cognition, and behavior.  These individuals are very sensitive to environmental circumstances.  They experience intense abandonment fears and inappropriate anger even when faced with a realistic time-limited separation or when there are unavoidable changes in plans (e.g., sudden despair in reaction to a clinician’s announcing the end of the hour; panic or fury when someone important to them is just a few minutes late or must cancel an appointment).  They may believe that this “abandonment” implies they are “bad.”  These abandonment fears are related to an intolerance of being alone and a need to have other people with them.  Their frantic efforts to avoid abandonment may include impulsive actions such as self-mutilating or suicidal behaviors, which are described separately in Criterion 5.

            Individuals with Borderline personality Disorder have a pattern of unstable and intense relationships (Criterion 2).  They may idealize potential caregivers or lovers at the first or second meeting, demand to spend a lot of time together, and share the most intimate details early in a relationship.  However, they may switch quickly from idealizing other people to devaluing them, feeling that the other person does not care enough, does not give enough, is note “there” enough.  These individuals can empathize with and nurture other people, but only with the expectation that the other person will “be there” in return to meet their own needs on demand.  These individuals are prone to sudden and dramatic shifts in their view of others, who may alternately be seen as beneficent supports or as cruelly punitive.  Such shifts often reflect disillusionment with a caregiver whose nurturing qualities had been idealized or whose rejection or abandonment is expected.

            There may be an identity disturbance characterized by markedly and persistently unstable self-image or sense of self (Criterion 3).  There are sudden and dramatic shifts in self-image, characterized by shifting goals, values, and vocational aspirations.  There may be sudden changes in opinions and plans about career, sexual identity, values, and types of friends.  These individuals may suddenly change from the role of a needy supplicant for help to a righteous avenger of past mistreatment.  Although they usually have a self-image that is based on being bad or evil, individuals with this disorder may at times have feelings that they do not exist at all.  Such experiences usually occur in situations in which the individual feels a lack of a meaningful relationship, nurturing, and support.  These individuals may show worse performance in unstructured work or school situations.

            Individuals with this disorder display impulsivity in at least two areas that are potentially self-damaging (Criterion 4).  They may gamble, spend money irresponsibly, binge eat, abuse substances, engage in unsafe sex, or drive recklessly.  Individuals with Borderline Personality Disorder display recurrent suicidal behavior, gestures, or threats, or self-mutilating acts (e.g., cutting or burning) and suicide threats or attempts are very common.  Recurrent suicidality is often the reason that these individuals present for help.  These self-destructive acts are usually precipitated by threats of separation or rejection or by expectations that they assume increased responsibility.  Self-mutilation may occur during dissociative experiences and often brings relief by reaffirming the ability to feel or by expiating the individual’s sense of being evil.

            Individuals with Borderline Personality Disorder may display affective instability that is due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days) (Criterion 6).  The basic dysphoric mood of those with Borderline Personality Disorder is often disrupted by periods of anger, panic, or despair and is rarely relieved by periods of well-being or satisfaction.  These episodes may reflect the individual’s extreme reactivity to interpersonal stresses.  Individuals with Borderline Personality Disorder may be troubled by chronic feelings of emptiness (Criterion 7).  Easily bored, they may constantly seek something to do.  Individuals with Borderline Personality Disorder frequently express inappropriate, intense anger or have difficulty controlling their anger (Criterion 8).  They may display extreme sarcasm, enduring bitterness, or verbal outburst.  The anger is often elicited when a caregiver or lover is seen as neglectful, withholding, uncaring, or abandoning.  Such expressions of anger are often followed by shame and guilt and contribute to the feeling they have of being evil.  During periods of extreme stress, transient paranoid ideation or dissociation symptoms (e.g. depersonalization) may occur (Criterion 9), but these are generally of insufficient severity or duration to warrant an additional diagnosis.  These episodes occur most frequently in response to a real or imagined abandonment.  Symptoms tend to be transient, last minutes or hours.  The real or perceived return of the caregiver’s nurturance may result in a remission of symptoms.” (p.706-708)

Diagnostic and Statistical Manual of Mental Disorders. 2000. 4^th ed. Washington, D.C.: American Psychiatric Association.

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Circadian Rhythm Sleep Disorder

(formerly Sleep-Wake Schedule Disorder)

 Diagnostic Features

            “The essential feature of Circadian Rhythm Sleep Disorder is a persistent or recurrent pattern of sleep disruption that results from a mismatch between the individual’s endogenous circadian sleep-wake system on the one hand, and exogenous demands regarding the timing and duration of sleep on the other (Criterion A).  In contrast to other primary Sleep Disorders, circadian Rhythm Sleep Disorder does not result from the mechanisms generating sleep and wakefulness per se.  As a result of this circadian mismatch, individuals with this disorder may complain of insomnia at certain times during the day and excessive sleepiness at other times, with resulting impairment in social, occupational, or other important areas of functioning or marked subjective distress (Criterion B).  The sleep problems are not better accounted for by other Sleep Disorders or other mental disorders (Criterion C) and are not due to the direct physiological effects of a substance or a general condition (Criterion D).

The diagnosis of Circadian Rhythm Sleep Disorder should be reserved for those presentations in which the individual has significant social or occupational impairment or marked distress related to the sleep disturbance.  Individuals vary widely in their ability to adapt to circadian changes and requirements.  Many, if not most, individuals with circadian-related symptoms of sleep disturbance do not seek treatment and do not have symptoms of sufficient severity to warrant a diagnosis.  Those who prevent for evaluation because of this disorder are most often troubled by the severity or persistence of their symptoms.  For example, it is not unusual for shift workers to present for evaluation after falling asleep while on the job or while driving.

The diagnosis of Circadian Rhythm Sleep disorder rests primarily on the clinical history, including the pattern of work, sleep, naps, and ‘free time.”  The history should also examine past attempts at coping with symptoms, such as attempts at advancing the sleep-wake schedule in delayed Sleep Phase Type.  Prospective sleep-wake diaries or sleep charts are often a useful adjunct to diagnosis.

 Subtypes

Delayed Sleep Phase Type.  This type of Circadian Rhythm Sleep disorder results from an endogenous sleep-wake cycle that is delayed relative to the demands of society.  Measurement of endogenous circadian rhythms (e.g., core body temperature) reflects this delay.  Individuals with this subtype (“night owls”) are hypothesized to have an abnormally diminished ability to phase-advance sleep-wake hours (i.e., to move sleep and wakefulness to earlier clock times).  As a result, these individuals are ‘locked in” to habitually late sleep hours and cannot move these sleep hours forward to an earlier time.  The circadian phase of sleep is stable:  individuals will fall asleep and awaken at consistent, albeit delayed, times when left to their own schedule (e.g., on weekends or vacations).  Affected individuals complain of difficulty falling asleep at socially acceptable hours, but once sleep is initiated, it is normal.  There is no concomitant difficulty awakening at socially acceptable hours (e.g., multiple alarm clocks are often unable to arouse the individual).  Because many individual with this disorder will be chronically sleep deprived, sleepiness during the desired wake period may occur.

Jet Lag Type.  In this type of Circadian Rhythm sleep Disorder, the endogenous circadian sleep-wake cycle is normal and the disturbance arises from conflict between the pattern of sleep and wakefulness generated by the circadian system and the pattern of sleep and wakefulness required by a new time zone.  Individuals with this type complain of a mismatch between desired and required hours of sleep and wakefulness.  The severity of the mismatch is proportional to the number of time zones traveled through, with maximal difficulties often noted after traveling through eight or more time zones in less than 24 hours.  Eastward travel (advancing sleep-wake hours) is typically more difficult for most individuals to tolerate than westward travel (delaying sleep-wake hours).

Shift Work Type.  In this type of Circadian Rhythm Sleep Disorder, the endogenous circadian sleep-wake cycle is normal and the disturbance arises from conflict between the pattern of sleep and wakefulness generated by the circadian system and the desired pattern of sleep and wakefulness required by shift work.  Rotating-shift schedules are the most disruptive because they force sleep and wakefulness into aberrant circadian positions and prevent any consistent adjustment.  Night- and rotating-shift workers typically have a shorter sleep duration and more frequent disturbances in sleep continuity than morning and afternoon workers.  Conversely, there may also be sleepiness during the desired wake period, that is, in the middle of the night work shift.  The circadian mismatch of the Shift Work Type is further exacerbated by insufficient sleep time, social, and family demands, and environmental disturbances (e.g., telephone, traffic noise) during intended sleep times.

Unspecified Type.  This type of Circadian Rhythm Sleep Disorder should be indicated if another pattern of circadian sleep disturbance (e.g., advanced sleep phase, non-24-hour sleep-wake pattern, or irregular sleep-wake pattern) is present.  An “advanced sleep phase pattern” is the analog of Delayed Sleep Phase Type, but in the opposite direction: individuals complain of an inability to stay awake in the evening and spontaneous awakening in the early morning hours.  “Non-24-hour sleep-wake pattern” denotes a free-running cycle:  the sleep-wake schedule follows the endogenous circadian rhythm period of approximately 24-25 hours despite the presence of 24-hour time cues in the environment.  In contrast to the stable sleep-wake pattern of the Delayed or advanced sleep phase types, these individuals’ sleep-wake schedules become progressively delayed relative to the 24-hour clock, resulting in a changing sleep-wake pattern over successive days.  “Irregular sleep-wake pattern” indicated the absence of an identifiable pattern of sleep and wakefulness.

 Associated Features and Disorders

Associated descriptive features and mental disorders.  In Delayed Sleep Phase Type, individuals frequently go to bed later and wake up later on weekends or during vacations, with a reduction in sleep-onset difficulties and difficulty awakening.  They will typically give many examples of school, work, and social difficulties arising from their inability to awaken at socially desired times.  If awakened earlier than the time dictated by the circadian timekeeping system, the individual may demonstrate “sleep drunkenness” (i.e., extreme difficulty awakening, confusion, and inappropriate behavior).  Performance often also follows a delayed phase, with peak efficiency occurring in late-evening hours.

            Jet Lag and Shift Work Types may be more common in individuals who are “morning types.”  Performance is often impaired during desired waking hours, following the pattern that would be predicted by the underlying endogenous circadian rhythms.  Jet lag is often accompanied by nonspecified symptoms (e.g., headache, fatigue, indigestion) that relate to travel conditions, such as sleep deprivation, alcohol and caffeine use, and decreased ambient air pressure in airplane cabins.  Dysfunction in occupational, family, and social roles is often observed in individuals who have difficulty coping with shift work.  Individuals with any Circadian Rhythm Sleep Disorder may have a history of alcohol, sedative-hypnotic, or stimulant use resulting from attempts to control their inappropriately phased sleep-wake tendencies.  The use of these substances may in turn exacerbate the Circadian Rhythm Sleep Disorder.

            Delayed Sleep Phase Type has been associated with schizoid, schizotypal, and avoidant personality features, particularly in adolescents.  “Non-24-hour sleep-wake pattern” and “irregular sleep-wake pattern” have also been associated with these same features.  Jet Lag and Shift Work Type may precipitate or exacerbate a Manic or Major Depressive Episode or an episode of a Psychotic Disorder.

 Diagnotic and Statistical Manual of Mental Disorders DSM-IV. 1994.  4^th ed.  Washington, D.C.: American Psychiatric Association.