ADHD: ATTENTION DEFICIT HYPERACTIVITY DISORDER

Signs & Symptoms of ADHD

Margaret V. Austin, Ph.D., edited by C. E. Zupanick, Psy.D.

Attention Deficit Hyperactivity Disorder (ADHD) is a neurological condition associated with several characteristic symptoms. These are:

1. distractibility,

2. poor impulse control,

3. forgetfulness,

4. inattention,

5. hyperactivity, and

6. impulsivity;

…beyond what is normal or average for a given age.

The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5; APA, 2013) is commonly used to describe and diagnose various mental disorders, including ADHD.

Inattention and impulsivity are hallmarks of ADHD. However, hyperactivity is not always present. In this case it would be called Attention Deficit Disorder (ADD) or ADHD, predominantly inattentive presentation.

Usually, ADHD is first identified during childhood; but, it often persists into adulthood. Although adult-ADHD is more common than once believed, not all children with ADHD will become adults with ADHD.

Symptoms of ADHD change across the lifespan. For example, some symptoms, like hyperactivity, fade over time. Moreover, the same symptom may be expressed differently by children and adults. For example, a child's chronic disorganization may appear as a messy room. When that child becomes an adult, chronic disorganization may be evidenced by repeated job loss due to an inability to effectively prioritize and sequence tasks. Because ADHD often "looks" different in children and adults, the adult version of the disorder will be discussed later.

SCHIZOPHRENIA

Symptoms of Schizophreniform Disorder

Rashmi Nemade, Ph.D. & Mark Dombeck, Ph.D., edited by Kathryn Patricelli, MA

Schizophreniform Disorder

This disorder is similar to but milder than schizophrenia. To be diagnosed, a person must have 2 or more of the following symptoms for a significant part of the time during a 1-month or longer period:

• Delusions - fixed, mistaken ideas that the person holds. These are often odd or incorrect ideas about themselves and the world around them.
• Hallucinations - sensations that only the person experiences. This can include voices speaking to them that only they can hear.
• Disorganized Speech - this can be switching topics frequently while talking, giving answers to questions that weren't asked or not being understandable by others.
• Very Disorganized or Catatonic Behavior - this might be childlike "silliness" or being agitated or irritated without a reason, or showing no reactions to the world around them.
• Negative Symptoms - this might be not having the full range of emotional expression that others do, having poor eye contract and little body movement; or not showing interest in participating in activities.

Additional criteria include:

• the episode must last for at least 1 month, but less than 6 months.
• schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out.
• the symptoms are not the result of a substance/medication taken or another medical condition.

SCHIZOPHRENIA

Symptoms of Schizoaffective Disorder

Rashmi Nemade, Ph.D. & Mark Dombeck, Ph.D., edited by Kathryn Patricelli, MA

Schizoaffective Disorder

Schizoaffective disorder shows both the psychotic thought problems of schizophrenia and the mood problems of major depressive disorder or bipolar disorder. It may be diagnosed when there is an uninterrupted period of illness during which the person has a major depressive or manic episode and also has the symptoms of the first criteria of schizophrenia which include 1 or more of the following happening for at least 1-month or longer:

• Delusions - fixed, mistaken ideas that the person holds. These are often odd or incorrect ideas about themselves and the world around them.
• Hallucinations - sensations that only the person experiences. This can include voices speaking to them that only they can hear.
• Disorganized Speech - this can be switching topics frequently while talking, giving answers to questions that weren't asked or not being understandable by others.
• Very Disorganized or Catatonic Behavior - this might be childlike "silliness" or being agitated or irritated without a reason, or showing no reactions to the world around them.
• Negative Symptoms - this might be not having the full range of emotional expression that others do, having poor eye contract and little body movement; or not showing interest in participating in activities.

Additional criteria for Schizoaffective disorder include:

• delusions or hallucinations for 2 or more weeks when a major depressive or manic episode is not happening.
• symptoms meet the criteria for a major mood episode for the majority of the active phase and residual parts of the illness.
• symptoms are not the result of a substance/medication taken or another medical condition.

Doctors often disagree on whether it is better to diagnose schizoaffective disorder, or to diagnose a bipolar or major depressive disorder and schizophrenia separately. There is no definite answer as to which practice is better at this time, because it is not known for sure at this time if schizoaffective disorder describes a single disease or not.

SCHIZOPHRENIA

Symptoms of Schizophrenia

Rashmi Nemade, Ph.D. & Mark Dombeck, Ph.D., edited by Kathryn Patricelli, MA

Schizophrenia

To be diagnosed with Schizophrenia, a person must have 2 or more of the following symptoms for a significant part of the time during a 1-month or longer period:

• Delusions - fixed, mistaken ideas that the person holds. These are often odd or incorrect ideas about themselves and the world around them.
• Hallucinations - sensations that only the person experiences. This can include voices speaking to them that only they can hear.
• Disorganized Speech - this can be switching topics frequently while talking, giving answers to questions that weren't asked or not being understandable by others.
• Very Disorganized or Catatonic Behavior - this might be childlike "silliness" or being agitated or irritated without a reason, or showing no reactions to the world around them.
• Negative Symptoms - this might be not having the full range of emotional expression that others do, having poor eye contract and little body movement; or not showing interest in participating in activities.

Additional criteria include:

• the person's level of functioning in terms of self-care, work, or relationships must show significant decline compared to before the symptoms were present.
• there must be continuous signs of disturbance for at least 6 months. This may include 1-month of active symptoms and then periods of lower symptoms where only negative symptoms are present.
• symptoms must not be part of Schizoaffective disorder or bipolar disorder or major depressive disorder with psychotic features.
• symptoms must not be the result of another medical condition or a substance/medication that was taken.
• If there is a history of autism spectrum disorder or a communication disorder, the diagnosis of schizophrenia can be made only if delusions or hallucinations are present, along with the other required symptoms of schizophrenia for at least 1 month.

SCHIZOPHRENIA

Symptoms of Delusional Disorder

Rashmi Nemade, Ph.D. & Mark Dombeck, Ph.D., edited by Kathryn Patricelli, MA

Delusional Disorder

Like schizophrenia, delusional disorder involves the presence of delusions that last for at least one month or longer. Delusions are fixed, mistaken ideas that the person holds. These are often odd or incorrect ideas about themselves and the world around them.

Unlike schizophrenia, however, hallucinations are either not present or are not prominent, unless related to the delusions. Delusional disorder also tends to start later in life than schizophrenia. Those with delusional disorder often are still able to care for themselves, work, have relationships and manage their daily lives.

For a diagnosis to be made, one or more delusions must be present for one month or longer.

The symptoms cannot be caused by another mental disorder or be the effects of a substance taken or other medical condition.

There are several subtypes that can be specified. These are made based on the main theme of the delusion(s) and include:

• Erotomanic type - when the delusion is that another person is in love with the individual (usually a famous person)
• Grandiose type - having the belief of having some great (but not recognized) talent or having made some important discovery
• Jealous type - believing that his or her spouse, partner or lover has been unfaithful
• Persecutory type - the individual believes that he or she is being plotted against, spied on, followed, poisoned or drugged, harassed, etc.
• Somatic type - the delusion involves bodily functions or sensations
• Mixed type - there is no one main theme of the delusion(s)
• Unspecified type - when the main belief of the delusion cannot be clearly determined or doesn't fit in the above types

SCHIZOPHRENIA

Symptoms of Brief Psychotic Disorder

Rashmi Nemade, Ph.D. & Mark Dombeck, Ph.D., edited by Kathryn Patricelli, MA

Brief Psychotic Disorder

People with brief psychotic disorder have delusions, hallucinations, and/or disorganized speech and behavior that lasts for at least one day, but less than one month. After the episode, their behavior returns to normal. These symptoms must not happen only as part of Schizophrenia, bipolar disorder or major depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder.

For a diagnosis to be made, a person must show one of the following:

• delusions - fixed, mistaken ideas that the person holds. These are often odd or incorrect ideas about themselves and the world around them.
• hallucinations - sensations that only the person experiences. This can include voices speaking to them that only they can hear.
• disorganized speech - this can be switching topics frequently while talking, giving answers to questions that weren't asked or not being understandable by others.
• very disorganized or catatonic behavior - this might be childlike "silliness" or being agitated or irritated without a reason, or showing no reactions to the world around them.

Clinicians can also add a specifier code to this disorder including:

• With marked stressor - this means that the symptoms are happening in response to an event that would be very stressful for almost anyone in that same situation
• Without marked stressor - there was no event that would be stressful to anyone in similar circumstances that brought about the symptoms
• With postpartum onset - the symptoms happen during pregnancy or within 4 weeks after having a child

SCHIZOPHRENIA

Symptoms of Schizophrenia

Rashmi Nemade, Ph.D. & Mark Dombeck, Ph.D., edited by Kathryn Patricelli, MA

Symptoms of Schizophrenia

Schizophrenia is identified by two groups of symptoms. These are called "positive" and "negative."

Positive symptoms are ones which are more than normal behavior. This group is further split into two groups. The "psychotic" group includes hallucinations and delusions. The "disorganized" one includes disorganized speech and behavior.

Negative symptoms involve missing behaviors compared to normal functioning. Examples include limited emotional expression, limited thought and speech, and lack of motivation.

Symptoms are not permanent things. Instead, they tend to change over time. A minimum number of symptoms (positive and/or negative) must be present before the diagnosis of schizophrenia can be made. It is very possible that a person may show some symptoms, but not enough of them to meet the formal diagnosis of schizophrenia for long periods of time. The maximum number of symptoms for the diagnosis will be present during the active phase (or "psychotic break") portion of the disorder. When enough symptoms are present and last for one month (or a shorter period if medication has been given) with some symptoms lasting for up to six months, a diagnosis of schizophrenia can be made. Once a formal diagnosis has been made, it can continue to be made later, even if some symptoms necessary for the diagnosis are no longer showing.

BIPOLAR DISORDER

Bipolar II Disorder and Cyclothymia

Rashmi Nemade, Ph.D. & Mark Dombeck, Ph.D., edited by Kathryn Patricelli, MA

Bipolar II Disorder

This type of bipolar disorder is characterized by one or more major depressive episodes with at least one hypomanic episode in which hospitalization is not required. By definition, no full manic episodes are present in Bipolar II.

The lifetime prevalence of Bipolar II Disorder internationally is 0.3% and is 0.8% in U.S. samples.

Cyclothymia

Cyclothymia is characterized by at least a two-year period of numerous hypomanic or depressive episodes, but none have been severe enough for a diagnosis of either full mania or major depressive disorder. Individuals with Cyclothymia do not remain symptom-free for more than two months at a time, by definition.

The diagnosis of cyclothymia cannot be made casually. Two full years of documented bipolar symptoms of the proper intensity must have been observed prior to diagnosis. If the mood swings can be better accounted for by the criteria of schizoaffective disorder, then that diagnosis occurs. If mood swings are considered to be a part of a larger schizophrenic disorder, then Cyclothymia becomes an associated feature of a psychotic disorder. If one or more mood episodes reach a severe stage where criteria for mania or major depressive disorder are met, then a diagnosis of Bipolar I or II is appropriate. Additionally, medical conditions such as hypothyroidism must be eliminated as the cause of bipolar symptoms before this diagnosis may be made. Substance-related disorders and sleep disorders may be associated with Cyclothymia.

Cyclothymic Disorder symptoms often begin adolescence or early adulthood. The condition typically has a slow, gradual, and progressive onset and a chronic course once established. There is a 15-50% chance that individuals with cyclothymia will go on to develop bipolar I or II disorders. In community samples, cyclothymic disorder symptoms are apparently equally common in men and in women. As with all bipolar disorders, a general medical condition or substance abuse problem must be excluded in order for this diagnosis to stand.

Lifetime prevalence of Cyclothymia is 0.4% to 1% in community samples. [DSM]

BIPOLAR DISORDER

Bipolar I Disorder

Rashmi Nemade, Ph.D. & Mark Dombeck, Ph.D., edited by Kathryn Patricelli, MA

This form of bipolar disorder occurs when a patient has experienced at least one complete full manic episode. The person may have also experienced hypomanic or major depressive episodes before or after the full manic episode.

For mania to be diagnosed, the episode must last for at least one week and be present most of the day, nearly every day. A variety of symptoms are possible during this episode. At least three of the following symptoms need to be present before the diagnosis can be made:

• an inflated, expansive, grandiose (and possibly delusional) sense of self
• decreased need for sleep (for example, feeling fully rested after 3 hours of sleep)
• more talkative than usual or pressure to keep talking
• the person feels a sensation of racing thoughts (often called a "flight of ideas")
• distractibility (for example, the person's attention is too easily drawn to unimportant or irrelevant stimuli). This can be reported by the person or observed by others around them
• an increase in goal-directed activity (purposeful behavior that occurs either socially, at work or school, or sexually), or physical agitation
• excessive involvement in activities that have a high potential for painful consequences (for example, going on a buying spree, unprotected sex, gambling, poor business investments, etc.)

Additional criteria for mania to be diagnosed include that the mood disturbances:

• are severe enough to cause a lot of stress or problems with school, work, relationships with others, or daily activities.
• do not happen because of a medication or substance that was taken, or because of another medical condition that the person has.

One mood episode is said to have occurred when a person shifts from one mood state into another and then back again. Most individuals with bipolar I disorder will shift repeatedly throughout their lives (moving from a depressed state into a manic state, or vice versa and then back again). Multiple months may be spent moving between states, however. Typically, each individual develops a personal pattern of episode timing to their disorder. They will tend to have manic episodes followed by depressive episodes in a characteristic pattern that is unique to them.

Suicide risk is a major concern for Bipolar I Disordered patients. Those with bipolar disorder are 15 times higher than in the general population. Suicidal behavior is most likely to occur during depressive or mixed feature states. During a manic phase, patients may participate in violent behavior, including behavior that would qualify as child and/or spouse abuse, but the risk of intentional suicide is less likely. Substance abuse issues, eating disorders attention-deficit/hyperactivity disorder (ADHD), and anxiety disorders (including panic attacks, social anxiety disorder and specific phobias) may occur with bipolar I disorder.

Both males and females diagnosed with bipolar I disorder tend to experience their first manic, hypomanic, or major depressive episodes around age 18. About 60% of manic episodes occur immediately before a major depressive episode. More than 90% of people who have a single manic episode will go on to have additional mood episodes.

Females with bipolar I disorder are more likely to experience rapid cycle and mixed states. They are also more likely than male patients to have depressive symptoms, and have a higher risk of alcohol use disorder.

Lifetime prevalence rates for Bipolar I Disorder in U.S. samples were 0.6% and ranged from 0.0-0.6% in studies across 11 countries.

BIPOLAR DISORDER

Bipolar Disorder - Major Depressive Episodes and Mixed Features

Rashmi Nemade, Ph.D. & Mark Dombeck, Ph.D., edited by Kathryn Patricelli, MA

Just as the manic aspect of bipolar disorder is associated with manic episodes, the depressive aspect of bipolar disorder is likewise associated with depressive episodes. The severe form of depressive episode is known as a Major Depressive Episode.

Someone having a Major depressive episode must experience five or more of the following symptoms during the same two-week period for most of the day or nearly every day:

• Feelings of sadness, emptiness, or hopelessness (in children, this may be irritability)
• Having no interest or feeling no pleasure in all or almost all activities
• Weight loss or weight gain by greater than 5% when not trying to lose or gain weight OR a change in appetite nearly every day
• Sleeping too little or too much
• Physical agitation or restlessness that is observed by others
• Being tired and having a lack of energy
• Feelings of worthlessness, self-hate, and guilt
• Not being able to concentrate, think clearly, or make decisions
• Being irritable
• Ongoing thoughts of death or suicide - either thinking about suicide without a plan for how it would happen, having a specific plan or attempting to commit suicide

Depressive symptoms can vary a great deal from one person to the next. One person with depression may experience feelings of sadness, hopelessness, and helplessness. Another person may feel angry, irritated, and discouraged. These symptoms may also seem like a change in someone's personality. For example, someone who is usually patient might begin to lose his or her temper about things that normally would not bother him or her.

Symptoms can also change over time when someone is depressed. Someone who is initially withdrawn and sad can become very frustrated and irritable as a result of getting less sleep and not being able to accomplish simple tasks or make decisions. These symptoms cause stress that is noticed by others and cause problems at school, work or in relationships with others.

Unlike with mania and hypomania, there is no short-term depressive episode that can be diagnosed. There is a related condition known as Persistent Depressive Disorder, or Dysthymia,, which describes a long-lasting mild depression. Dysthymia cannot be diagnosed at the same time as bipolar disorder. This is because in order to qualify for a diagnosis of Dysthymia, you have to show evidence of consistently mild depressive symptoms occurring more days than not over a period of at least two years. The presence of manic or hypomanic episodes during the two-year period would disqualify a person from being diagnosed with Dysthymia.

Mixed Features

While bipolar disorder most frequently happens as a swing between manic and depressive episodes, in a minority of cases, a third type of episode can happen. One of the specifiers for Bipolar Disorder can be "with mixed features." This means that the criteria for mania and the criteria for depression are both simultaneously met. However, just because criteria for both manic and depressive episodes are both met during a single day, for example, does not mean that both sets of symptoms are present at the same time. Instead, what typically happens is that there is a rapid switching between manic and depressive states, happening one or more times in a single day. These mixed features tend to be severe when they occur with psychotic symptoms such as hallucinations and delusions, and suicidal thinking frequently present.

BIPOLAR DISORDER

Hypomania and Hypomanic Episodes Defined

Rashmi Nemade, Ph.D. & Mark Dombeck, Ph.D., edited by Kathryn Patricelli, MA

Not everyone who becomes manic experiences a full-blown manic episode. Hypomanic individuals show an energized and sometimes elated mood, with rapid thinking and talking.

At least three of the following must be present (for at least four days) before the diagnosis of hypomanic episode is appropriate:

• an inflated sense of self (the person believes they are much better, smarter or more powerful than anyone else around them). With hypomania, the sense of self is never delusional or completely out of touch with reality
• decreased need for sleep (for example, feeling fully rested after 3 hours of sleep)more talkative than usual or pressure to keep talking
• the person feels a sensation of racing thoughts (often called a "flight of ideas")distractibility (for example, the person's attention is too easily drawn to unimportant or irrelevant stimuli). This can be reported by the person or observed by others around theman increase in goal-directed activity (purposeful behavior that occurs either socially, at work or school, or seuxally), or physical agitation
• excessive involvement in activities that have a high potential for painful consequences (for example, going on a buying spree, unprotected sex, gambling, poor business investments, etc.)

You'll notice that these are essentially the same criteria that are applied to manic episodes. What separates a hypomanic episode from a manic episode is mostly the degree of intensity (or energy) present in the behaviors that the manic person shows. It's the degree of intensity, not the variety of ways it's displayed. When the observed energy level is above average but still within normal limits, you have a hypomanic state. When the energy level goes off the normal scale entirely, you have a manic episode.

People experiencing a hypomanic state are not necessarily always sunny and happy. They may experience irritable mood states too, as is also the case with full manic episodes. However, the level of irritability that may be shown during a hypomanic episode is nowhere near as severe as what might be shown during a fully manic episode.

Since hypomania is less severe than mania, people experiencing a hypomanic episode may still have sound judgment and not engage in self-destructive behavior. In fact, their sharpened thoughts and ability to function with little sleep contribute to increased productivity compared to those without mania. Hypomania can create a distinct advantage in the workplace because it helps people to be very productive and get more things done than others can do. This positive aspect of hypomania is often seen as a benefit by people who have bipolar disorder.

Hypomanic individuals are likely to be creative risk-takers, who can make creative ideas happen. Many historical and contemporary figures, including composer Ludwig van Beethoven, pioneering physicist Issac Newton, authors Charles Dickens and Edgar Allen Poe, artist Vincent van Gogh, statesmen Abraham Lincoln, Winston Churchill and Theodore Roosevelt, and media mogul Ted Turner have been documented to have experienced severe and debilitating recurrent mood swings. When you are hypomanic on a regular basis, you have a mild form of what can be a disabling illness. There is no guarantee that your hypomania will stay stable as hypomania. When left untreated, the underlying causes that produce hypomania can, and do sometimes, worsen until full manic episodes occur.

DEPRESSION: DEPRESSION & RELATED CONDITIONS

Premenstrual Dysphoric Disorder

Rashmi Nemade, Ph.D., edited by Kathryn Patricelli, MA

Symptoms of this condition can include:

• feeling depressed or having mood swings
• feeling anxious
• being easily tired or not having interest in normal activities
• being irritable
• having changes in eating or sleeping habits irritability
• feeling overwhelmed and out of control

Symptoms occur repeatedly during the premenstrual phase of the woman's cycle and decrease or disappear around the onset of her period or shortly after. Symptoms must occur in most of the menstrual cycles during the past year. They also must make it difficult to work or interact with other people. Women who have major depressive disorder tend to experience this condition as well.

How this disorder is displayed can be closely related to social and cultural background characteristics. These can include family perspectives, religious beliefs, social tolerance, and female gender role issues. For example, in some families or cultures, women can express sadness or irritability with ease. In other families or cultures, women are expected to be silent followers of male leaders and not express their feelings or thoughts. While in other religions and cultures, the menstrual cycle is a time of rest and respect for women, and women are excused from daily tasks in order to deal with their biology. In this situation, women may feel more free to display any emotional or depressive symptoms they are experiencing. Thus, this particular condition is tied closely to cultural, social, and religious perspectives of women and women's issues in general.

Approximately 1.8% to 5.8% of menstruating women suffer from this condition. It can happen at any time after a woman's first period. Many women report symptoms get worse as they approach menopause. However, after menopause symptoms stop. If hormone replacement treatment is used, then symptoms can happen again. It is not currently known whether this condition has genetic risk factors or runs in families. Because of the social, cultural, and religious perceptions of women, the range for estimating if this disorder is inherited is between 30% to 80%.

Additional environmental risk factors include stress, history of trauma, and seasonal changes. Women who use oral contraceptives ("the pill") may have fewer symptoms than women who do not use them.

While this condition is displayed and accepted in a variety of different ways in various societies, it is not a bound to any one culture, religion, society, ethnicity, or country. It is found all over the world. However, how often it happens, how intense it is, how it is displayed, and if women/families seek help are strongly influenced by where the woman lives. For example, if a woman lives in a culture that ignores this condition and brushes it off as a women's problem that does not require medical attention, she will likely not seek help. But if that same woman moves to a more accepting culture or marries into a more accepting family, she may go on to receive medical attention. Symptoms can affect marriages, relationships with children or other family members, and can cause problems at work.

There are a number of medical and mental health conditions that may make this condition worse. These include asthma, allergies, seizure disorders, depressive and bipolar disorders, anxiety disorders, bulimia nervosa, and substance use disorders.

DEPRESSION: DEPRESSION & RELATED CONDITIONS

Prevalence and Co-Occurring Conditions

Rashmi Nemade, Ph.D., edited by Kathryn Patricelli, MA

Although major depressive disorder (MDD) can appear at any age, it typically is first seen during puberty. The highest rate of MDD is seen with people in their 20's but can easily occur later in life. In any 12-month period, about 7% of the population has MDD. There are differences by age group that are seen. For example, the people who are 18-29-years old are 3 times more likely to have major depressive disorder than people who are 60 or older. Women experience MDD at a rate that is 1.5-3 times higher than men beginning in early adolescence.

People with major depressive disorder often have substance-related disorders, panic disorder, obsessive-compulsive disorder, eating disorders, and borderline personality disorder.

Formal DSM Diagnoses for Other Depressive Disorders

As mentioned in the introduction to this center, we are primarily focusing this discussion on Major Depressive Disorder. However, we also want to take some time to briefly discuss some other disorders that can share symptoms with Major Depressive Disorder. These include:

• Disruptive Mood Dysregulation Disorder
• Persistent Depressive Disorder (Dysthymia)
• Premenstrual Dysphoric Disorder
• Substance/Medication-Induced Depressive Disorder
• Depressive Disorder Due to Another Medical Condition
• Unspecified Depressive Disorder

As you can tell by the length of the above list of conditions, determining which of these best describes a person's particular collection of depression symptoms can be tricky. At times, clinicians must "play detective" as they try to piece together an explanation for why someone feels depressed. You may wonder why a mental health professional spends so much time and effort coming up with a specific label. After all, people who have depressive symptoms feel bad, and have some level of trouble that impacts their ability to function in their daily lives.

A correct diagnostic label can help a therapist narrow down the treatment options, and then get the person on the road to recovery more quickly. A medical example may be helpful here. There is a wide variety of reasons that someone can develop a fever. This could include having a cold, strep throat, cancer, or rheumatoid arthritis. The doctor must spend some time determining the exact cause of the symptoms in order to prescribe the appropriate treatment. Obviously, the treatments for a cold and cancer are very different, so pinpointing the diagnosis is important. Similarly, there are a long list of reasons why someone develops depressive symptoms. Finding out the cause (and the best treatment) is no less important when it comes to treating a depressive disorder. We'll talk about the strategies used to come up with the best diagnosis in a later section of this center.

DEPRESSION: DEPRESSION & RELATED CONDITIONS

Differential Diagnosis and Specifiers of Major Depressive Disorder

Rashmi Nemade, Ph.D., edited by Kathryn Patricelli, MA

In addition to making a diagnosis of a particular disorder, a clinician can also say how it is different from other conditions that may have similar symptoms. This is known as a differential diagnosis. This information can help a clinician narrow down which treatments may work best for the patient. It may also be used to provide information about a person's anticipated course of the disorder and their prognosis (outcome).

For example, a differential diagnosis of MDD with attention-deficit/hyperactivity disorder narrows down the diagnosis to describe that a person is highly distractible and irritable during a depressive episode rather than just being sad.

Clinicians may use the following differential diagnoses to describe the current or most recent Major Depressive Disorder:

• Manic episodes with irritable mood or mixed episodes - in this situation, the person may be very irritable or have mood symptoms that are similar to those seen in bipolar disorder.
• Mood disorder due to another medical condition - the person has a medical condition such as multiple sclerosis, stroke, or heart disease and is also experiencing depression. It is important for a clinician to understand whether a person is depressed because they have a true mood disturbance or if their depression is due to a medical condition. In this case, treatment options might be very different.
• Substance/medication-induced depressive or bipolar disorder - This description is used when the depressive symptoms are related to the use of a substance (medication or drug of abuse). For example, a person suffering from cocaine withdrawal would be diagnosed as cocaine-induced depressive disorder.
• Attention-deficit/hyperactivity disorder - people with this type are distracted and easily frustrated. This can be a tricky diagnosis in children because instead of being sad or losing interest, children tend to become irritable with depression.
• Adjustment disorder with depressed mood - this is used when not all the criteria are met for MDD and the depressive episode occurs in response to a stressful event involving other people such as a death or loss (divorce).
• Sadness - Feeling sad is part of being human, and everyone has periods when they feel sad. These should not be diagnosed as MDD unless the DSM criteria for MDD have been met and a person is unable to function because of their sadness.

Clinicians can also label the episode as occurring with:

Anxious Distress - this is when a person feels keyed up/tense, is unusually restless, or has a feeling or fear that something awful may happen or they may lose control. A clinician will typically label the disorder as mild to severe based on the number of anxiety symptoms the person experiences along with MDD.

Mixed Features - These are behaviors that are typically observed by others and represent a change from the person's usual behavior. They include:

• Elevated, expansive mood - someone who may express hostility, criticism and be emotionally over-involved in life events. Typically, they consider themselves very important;
• Inflated self-esteem or grandiosity - someone who believes themselves to be larger than they are. For example, they believe that they have special powers, spiritual connections, or religious relationships;
• More talkative than usual - someone who cannot stop themselves from talking or in a group cannot stop long enough for others to contribute to a conversation;
• Racing thoughts - this is when someone's thoughts race or go very fast, so fast that their thoughts change very quickly;
• Increase in energy and goal-directed activity - when a person goes from being low energy and motivation with few goals to suddenly having energy, goals, and is motivated to pursue and achieve goals;
• Increased or excessive involvement in activities that may be dangerous or risky - this might include skydiving, risky business investments, or sexual behavior that is not usual for the person
• Decreased need for sleep - the high energy and goal-directed activity may result in less sleep because of the new goals to be achieved.

To others, this behavior may seem exaggerated, boastful, and pompous and the person is felt to be conceited. These behaviors fall into the manic category. If these symptoms appear, but do not seem as extreme or as severe as mania (such as having all the symptoms), then that person is said to be hypomanic (having just a few or all, but in a more subdued way). If at least three of these manic/hypomanic symptoms are present nearly every day during the most of the days that the person has a major depressive episode, then the person is said to have mixed features along with MDD. NOTE: Mixed features with MDD are found to be a risk factor for a person developing bipolar I or bipolar II disorder.

Melancholic Features - A person is said to have MDD with melancholic features if at the most severe stage of the episode if he/she shows:

• An inability to enjoy anything and does not react to anything pleasurable along with a mood that is regularly worse in the morning
• early morning awakening (at least two hours before the usual time)
• thinking or moving slowly or speeding up of physical activity (agitation)
• significant loss of appetite or unplanned weight loss
• excessive or inappropriate guilt.

Atypical Features - this is when MDD occurs with mood reactivity. For example, the person's mood brightens when good things happen, when they gain weight or have an increase in appetite, sleep more than usual, or have heavy almost paralyzing feeling in their arms and legs. These features should not occur in the same episode with melancholic or catatonic features.

Psychotic Features - this is used when delusions and/or hallucinations are experienced. When the delusions and/or hallucinations are consistent with typical depressive feelings such as personal weakness, guilt, disease, or deserved punishment, they are said to be mood-congruent. When they do not follow typical depressive feelings, but are instead the opposite or a mixture of the two, they are known as mood-incongruent.

Catatonia - In MDD with catatonia, a person displays one or many unusual movements and mannerisms, including:

• stupor (periods during which they do not move or actively relate to the environment)
• excessive movement
• catalepsy (passively being put into postures and holding them for periods of time, sometimes against gravity)
• waxy flexibility (resistance to positioning)
• mutism (no verbal response)
• negativism (opposition or no response to instructions)
• posturing (spontaneous and active maintenance of a posture held against gravity)
• mannerism (odd caricature of normal actions)
• stereotypy (repeating behaviors over and over without a goal)
• prominent grimacing; echolalia (mimicking someone else's speech)
• echopraxia (mimicking another's movements).

For example, a person sitting on a park bench who seems unable to stop imitating gestures and words of passers-by might be suffering from MDD with catatonic features.

Peripartum Onset - this is used if the onset of MDD occurs during pregnancy or in the 4 weeks following childbirth. This is just when the symptoms first appear, but they may last longer than the noted four weeks. Because 50% of 'postpartum' depressive episodes begin during pregnancy, this category is now called peripartum rather than postpartum.

Common symptoms include changing moods and high preoccupation with the baby's well-being. It is very normal for parents to be concerned about their new babies and their parenting skills. However, calling the doctor multiple times each day for weeks on end is not typical parenting behavior. Excessive worry about typical newborn behaviors, such as straining during a bowel movement, and treating these behaviors as a major medical event requiring immediate attention is also not normal behavior.

Postpartum depression can also include psychotic thinking with unshakable false beliefs (delusions). Delusional thoughts that include themes of harming the infant are particularly dangerous. For example, a mother may hallucinate that the baby or other people are telling her that she is a bad mother, hear voices that tell her to kill the baby, or think that her infant is possessed. Infanticide (murder of an infant) is most common with women who experience delusions or hallucinations; but women who are severely depressed without psychotic features have also killed their children. If a woman has mood and anxiety symptoms during pregnancy, she is more likely to experience a postpartum major depressive episode. In addition, once a woman has had a postpartum depressive episode with psychotic features; her risk of having a similar episode with each subsequent delivery is between 30-50%.

Seasonal Pattern - this occurs when a person experiences depressive symptoms at a particular time of year, and then feels a lifting of symptoms at other times of the year on a regular basis for the past two years. For example, if a person's depressive symptoms typically start in the fall or winter and lift in the spring, this individual is diagnosed with MDD with a seasonal pattern.

It is important to separate this from other stressful events, such as seasonal unemployment during the winter or a school schedule. Typically, for a person to be diagnosed with a seasonal pattern, they must have more seasonal episodes than nonseasonal episodes during their lifetime. This disorder can occur as mild, moderate or severe in individuals depending on the level of problems that the person has doing their daily activities (work, school, etc.).

This pattern has been previously called Seasonal Affective Disorder. However, in the DSM-5, it is seen as a variation of Major Depressive Disorder and not something unique or separate from MDD. Seasonal Affective Disorder is not considered a disorder or condition on its own.

When the winter months start and daylight grows shorter, some people start feeling a little slow, experience a bit of weight gain, have difficulty getting out of bed, and have periods of "the blues". Symptoms begin in the fall, peak in the winter and usually resolve in the spring. The typical symptoms of this seasonal pattern include low mood, lack of energy, changes in appetite and sleep, feelings of guilt and self-blame, and hopelessness.

Most people with this pattern experience relatively mild symptoms, but others have more crippling symptoms that cause problems at school, work or in the relationships with others.

DEPRESSION: DEPRESSION & RELATED CONDITIONS

The Development and Course of Major Depressive Disorder

Rashmi Nemade, Ph.D., edited by Kathryn Patricelli, MA

It is now understood that major depressive disorder (MDD) can first occur at any age. Most of the time it appears more noticeably at the start of puberty. The highest rate occurs with people in their 20s, but it is not uncommon for people to experience depression later in life. The course of MDD differs widely. It can last for short periods of time with mild symptoms or long periods of time with severe symptoms, and any variation in between. Typically, clinicians try to figure out how long a person has had symptoms. The longer and more severe the symptoms, the more chances of there being a personality, anxiety, or substance use problem that may be causing or contributing to the depressive symptoms. Recovery is variable as well. If an individual has been depressed for only a few months, they can often recover quickly. However, if a person has severe symptoms, has been depressed for several months to years, or has another condition, such as an anxiety or personality disorder, then recovery may take much longer.

How often one experiences MDD depends on how long they feel depressed and the severity of their symptoms. If someone only feels depressed for a month or so every few years, they probably won't experience MDD very often. The risk for recurring depression is higher in individuals who have had severe, crippling episodes. It is important to note that MDD, particularly with psychotic features, such as hallucinations or delusions, can also transition into schizophrenia.

More women experience MDD than men. However, there are no differences in the age it first occurs, the course, or response to treatment between the genders. The likelihood of suicide goes down the older the person gets, but the course and recovery of MDD does not change with aging.

There are risk factors that can lead people to develop MDD such as temperament, environment, or genetics. Temperament is the combination of mental, physical, and emotional features of a person (their personality). People who have a negative outlook on life or temperament have a natural tendency to develop MDD in response to stressful life events. Stressful events are environmental risk factors that can trigger MDD. These may include the death of a loved one or other major losses such as losing a job or going through a separation or divorce. Other life changes may trigger depression as well. Even normal developmental milestones such as puberty, marriage, or retirement may trigger depression when a particular event is personally distressing to a particular person. For example, a person who loved their job may become depressed after they retire. These stressful situations may be recent, or they may be past events that are strongly remembered for some reason. For example, thinking deeply about stressful past experiences such as emotional, physical, or sexual abuse can trigger an onset of depression. Individuals with Post-Traumatic Stress Disorder (PTSD), who have experienced a traumatic event such as military battle, rape, severe automobile accident or natural disaster are more likely to suffer from depression than people who have not experienced such trauma. When there are multiple and different negative childhood experiences, there is a higher tendency to develop MDD. Major depressive disorder also has runs in families. People who have a parent, brother or sister with major depressive disorder are 2-4 times more likely to develop the disorder themselves than those in the general population. Approximately, 40% of those with MDD have a genetic link to the disorder.

There are also disorders or medical conditions that can increase the risk for developing MDD or making it worse. Examples include substance use, anxiety disorders, and borderline personality disorder. In these situations, treatment and recovery depends on finding the true cause of MDD. Long-term or crippling medical conditions such as diabetes, morbid obesity and heart disease are also risk factors for MDD. There is currently no lab test (such as a blood test or brain scan) that can confirm whether a person has MDD. However, some lab tests can appear different than normal during an active depressive episode. For example, differences in measurements of electrical activity in the brain during sleep have been found in 90% of people who are hospitalized for MDD. Even people with depression who do not have symptoms severe enough to require hospitalization often show these differences. Other differences in brain chemicals and hormones also occur with depression. At this time, none of these tests are reliable or specific enough to prove that the cause is major depressive disorder.

Even though lab tests aren't used to diagnose depression, doctors will often request them. These can be helpful in finding other conditions such as thyroid trouble, cancer, arthritis, and other diseases that might be causing the depressive symptoms. Later in this center, we will discuss more about how clinicians diagnose depression using lab tests, psychiatric interviews and self-report questionnaires. Symptoms of Major Depressive Disorder usually develop over a few days or weeks. Many people feel anxious or mildly depressed for a while before a full depressive episode becomes apparent. Often, the symptoms eventually disappear and functioning returns to normal. The DSM-5 provides labels that describe the course of a person's Major Depression:

• "full remission" means there are no current depressive symptoms
• "partial remission" means that the person currently has fewer than five depressive symptoms or has had no symptoms at all for less than two months;
• "chronic" means that a person has met all of the diagnostic criteria for Major Depressive Disorder for two or more years.

Approximately 20-30% of people with Major Depressive Disorder experience partial remission of symptoms, while 5-10% of people have chronic MDD.

Suicide is a risk during times of MDD episodes. Women have a higher risk of suicide attempts, but their risk for being successful is lower. This is because they often choose methods such as an overdose rather than use of a gun. A history of suicide attempts or threats greatly increases the risk of a successful suicide attempt, but it is important to note that most completed suicides are done by those who have never attempted it before.

DEPRESSION: DEPRESSION & RELATED CONDITIONS

Classic Symptoms of Major Depressive Disorder

Rashmi Nemade, Ph.D., edited by Kathryn Patricelli, MA

The American Psychiatric Association (APA) publishes the Diagnostic and Statistical Manual of Mental Disorders (DSM). This manual describes the symptoms necessary for the diagnosis of all mental disorders, including Major Depressive Disorder. The DSM is updated when research and changes in the medical system make it necessary to revise old diagnoses. For example, in the last edition of the DSM, bipolar disorder was classified under MDD. In the most current edition (DSM-5), bipolar disorder is now a completely separate diagnostic category.

The Depressive Disorders category now includes:

• Major Depressive Disorder
• Disruptive Mood Dysregulation Disorder
• Persistent Depressive Disorder (Dysthymia)
• Premenstrual Dysphoric Disorder
• Substance/Medication-Induced Depressive Disorder
• Depressive Disorder Due to Another Medical Condition
• Unspecified Depressive Disorder

These conditions are all similar in that they all have something to do with having a depressed mood. They are separated by the severity of the depression or by what may be causing it.

A person is diagnosed with Major Depressive Disorder when:

• they experience five or more of the following symptoms during the same two-week period for most of the day or nearly every day:

- Feelings of sadness, emptiness, or hopelessness (in children, this may be irritability)

- Having no interest or feeling no pleasure in all or almost all activities

- Weight loss or weight gain by greater than 5% when not trying to lose or gain weight OR a change in appetite nearly every day

- Sleeping too little or too much

- Physical agitation or restlessness that is observed by others

- Being tired and having a lack of energy

- Feelings of worthlessness, self-hate, and guilt

- Not being able to concentrate, think clearly, or make decisions

- Being irritable

- Ongoing thoughts of death or suicide - either thinking about suicide without a plan for how it would happen, having a specific plan or attempting to commit suicide

• Never having a manic or hypermanic episode (being very excited or energetic which would be possible symptoms of bipolar disorder)
• these symptoms cause a great deal of stress in the person's life or cause changes in their daily activities such as not being able to get out of bed, getting ready for the day, and/or handling school, work, relationships, and other commitments.
• at least one of the symptoms is depressed mood or loss of interest or pleasure

Symptoms of MDD

Depressive symptoms can vary a great deal from one person to the next. One person with depression may experience feelings of sadness, hopelessness, and helplessness. Another person may feel angry, irritated, and discouraged. These symptoms may also seem like a change in someone's personality. For example, someone who is usually patient might begin to lose his or her temper about things that normally would not bother him or her.

Symptoms can also change over time when someone is depressed. Someone who is initially withdrawn and sad can become very frustrated and irritable as a result of getting less sleep and not being able to accomplish simple tasks or make decisions. These symptoms cause stress that is noticed by others and cause problems at school, work or in relationships with others.

It is important to note that a diagnosis of MDD is not made when the cause is a substance (medication or drug of abuse) that the person took or because of another medication condition. People usually go to the doctor with complaints of disturbed sleep (not able to sleep or sleeping too much) or tiredness. Even though they may deny sadness, through careful interviewing, facial expressions, and body language, the doctor can often figure out if a person is feeling depressed.

When major depressive disorder is severe, people may experience psychotic symptoms, such as hallucinations and delusions. Hallucinations are "phantom" sensations that appear to be real even though they are not caused by real things in the environment. Hallucinations may involve sights, sounds, tastes, smells or sensations. They can be very convincing, as well as disturbing. The most common form of hallucination involves hearing voices of people who are not actually present.

Delusions are very strongly held false beliefs that cause a person to misinterpret events and relationships. Delusions vary widely and examples include:

• persecutory (someone is spying on or following you)
• referential (a television show or song lyrics contain special messages only for you)
• somatic (thinking that a body part has been altered or injured in some way)
• religious (false beliefs with religious or spiritual content)
• erotomanic (thinking that another person, usually someone of higher status, is in love with you),
• grandiose (thinking that you have special powers, talents, or that you are a famous person).

When someone is depressed, these hallucinations and delusions usually focus on guilt, personal weaknesses, or disease. For instance, someone who is depressed might truly believe that they are not able to do their job or take care of their child because they are a failure. This feeling may be reinforced by voices telling them that they are weak or a belief that everyone is laughing at them behind their back. This can be especially troubling because a person can lose the ability to figure out the difference between real and imagined experiences in this situation.

In this center, we focus on Major Depressive Disorder, Disruptive Mood Dysregulation Disorder, Persistent Depressive Disorder (Dysthymia), Premenstrual Dysphoric Disorder, Substance/Medication-Induced Depressive Disorder, Depressive Disorder Due to Another Medical Condition, and Unspecified Depressive Disorder. For information on Bipolar Disorder, please visit our center on that topic. Throughout our discussion it is important to keep in mind that the term "depression" is not very specific. There are multiple kinds of depression; and the diagnosis of a particular condition varies depending on how severe the symptoms are and how long they last.

SUICIDE

What Are Other Suicide Warning Signs?

Natalie Staats Reiss, Ph.D., and Mark Dombeck, Ph.D.

In addition to suicidal thoughts, there are other warning signals that suggest suicide risk as well as the possible presence of a mental or physical illness. Of particular concern are signs and symptoms that are changes from a person's normal behavior, appearance, and functioning.

Additional warning signs of suicide can include:

• decreased performance in school or work
• an unusual desire for social isolation
• a significant decrease in self-esteem
• increased emotionality (expressed as anger, agitation, anxiety, hopelessness, sadness, or similar emotion)
• a sudden decrease in emotionality; particularly, a movement from depression or agitation to remarkable and uncharacteristic calm
• uncharacteristic behaviors or emotions
• uncharacteristic carelessness concerning personal safety
• increased drug and/or alcohol use
• losing interest in things that someone used to enjoy
• failing to take prescribed medications or follow required diets
• preparing for death by getting one's affairs "in order"

Excessive behavioral changes in any direction (e.g., towards agitation or towards calmness) beyond what might normally be expected following a loss or emotional insult are worth pointing out and exploring with a potentially suicidal person. For example, people who are recovering from depression should be watched for possible suicide warning signs during the period of their recovery. An increase in their energy level can provide the ability to act upon suicide thoughts they've been nursing while depressed but were too exhausted to do anything about.

Similarly, sudden and uncharacteristic calm after a period of depression or agitation can come on as a result of people having made the decision to kill themselves. People may become calm because they believe that their impending death will finally solve their overwhelming problems. In a similar way, any person who suddenly begins arranging their affairs and "tying up loose ends" (e.g., giving away personal items) or makes plans to move after having experienced a period of depression and severe personal struggle may actually be planning suicide.

In following up on such changes with a potentially suicidal person, keep in mind that your concern will in some cases represent a false positive concern. There may be no actual suicidality present. It is important to follow up anyway, given how important it is to identify actual suicidal intent before it progresses towards an actual suicidal attempt.

Suicidality generally progresses from idea, to plan, to actual attempt. Once seriously suicidal people have decided to end their lives, they will generally start assembling a "suicide kit" by gathering those necessary tools and ingredients to accomplish their goal. For instance, people who have decided to overdose on pills may start stockpiling medicine. People who decide to shoot themselves may need to purchase a gun or ammunition. Attempts to obtain tools that might be used for suicide can then also become a warning sign for significant suicide risk. This can be a difficult warning sign to spot as many such tools are common household items, and many homes already have guns in them.

People whose level of suicidality has progressed to the point where they are presently engaged in assembling the means of their suicide are in acute, immediate, and substantial danger of harming themselves. If you observe someone possibly assembling the means to end his or her life, that person's suicide risk level has become extremely high. The time to ask about suicidality is right now. The time to drive the suicidal person to the hospital may be now as well.

Warning signs for suicide are not typically obvious and can be very difficult to spot in advance. If you are reading this information after your friend or family member has already attempted or committed suicide, don't beat yourself up if you missed what now seem like obvious warning signs. It is usually far easier to recognize warning signs later on than to catch them prior to a suicide attempt being made. You are not stupid, insensitive, and/or clueless if you didn't know that someone was suicidal. Even the best trained mental health professionals can miss some suicidal warning signs, particularly if those signs are very subtle.

SLEEP DISORDERS

Central Sleep Apnea

Kathryn Patricelli, MA

What is Central Sleep Apnea?

This disorder occurs when the brain doesn't send the right signals to start the breathing muscles during sleep, which causes the person to temporarily stop breathing. There is generally no airway blockage are there is with Obstructive Sleep Apnea Hypopnea.

Symptoms include a sleep study test finding that a person has at least 5 episodes of total absence of airflow or reduced airflow per hour during sleep, and that these episodes are not caused by another sleep disorder.

There are 3 subtypes of this disorder including:

• Idiopathic Central Sleep Apnea - repeated episodes of total absence of airflow or reduced airflow during sleep that are caused variations in breathing, but without any sign of an airway blockage.
• Cheyne-Stokes Breathing - a pattern of rising and falling breathing that results in at least 5 episodes per hour of total absence of airflow or reduced airflow during sleep. This type typically happens due to heart failure, stroke or kidney failure. People with this type are often older, male and have lower weight than those with Obstructive Sleep Apnea Hypopnea.
• Central Sleep Apnea resulting from Opioid Use - the breathing problems are because of the use of an opioid medication (including drugs like morphine, heroin, codeine, methadone, and oxycodone).

How common is Central Sleep Apnea?

Exact rates are not known for this disorder, but it is thought to be a rare condition.

What are the risk factors for Central Sleep Apnea?

Risk factors for the Cheyne-Stokes type include heart failure, stroke and kidney failure. The Opioid use type can occur in those that take the medications for long periods of time.

What other disorders or conditions often occur with Central Sleep Apnea?

This disorder frequently occurs in those that take opioids, such as methadone. Obstructive Sleep Apnea Hypopnea can also occur with this condition. Those with the Cheyne-Stokes type usually also have heart failure, stroke or kidney failure.

How is Central Sleep Apnea treated?

Treatments often involve addressing the medical condition that may be causing this disorder, such as heart or kidney failure. A CPAP (continuous positive airway pressure) machine that has a mask that fits over your mouth and nose, or just over your nose, and blows air into the throat can be used.

Supplemental oxygen use may also be recommended, as well as medications that can help increase breathing.

CONVERSION DISORDERS

Symptoms - Conversion Disorder

Kathryn Patricelli, MA

Conversion Disorder

Symptoms

One or more symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or other general medical condition.

Psychological factors are judged to be associated with the symptom or deficit because the initiation or exacerbation of the symptom or deficit is preceded by conflicts or other stressors.

The symptom or deficit is not intentionally produced or feigned (as in Factitious Disorder or Malingering).

The symptom or deficit cannot, after appropriate investigation, be fully explained by a general medical condition, or by the direct effects of a substance, or as a culturally sanctioned behavior or experience.

The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.

The symptom or deficit is not limited to pain or sexual dysfunction, does not occur exclusively during the course of Somatization Disorder, and is not better accounted for by another mental disorder.

Criteria summarized from:

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, fourth edition. Washington, DC: American Psychiatric Association.

CONVERSION DISORDERS

Illness Anxiety Disorder

Kathryn Patricelli, MA

Hypochondriasis

Symptoms

Preoccupation with fears of having, or the idea that one has, a serious disease based on the person's misinterpretation of bodily symptoms.

The preoccupation persists despite appropriate medical evaluation and reassurance.

The belief in the first category is not of delusional intensity (as in Delusional Disorder, Somatic Type) and is not restricted to a circumscribed concern about appearance (as in Body Dysmorphic Disorder).

The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

The duration of the disturbance is at least 6 months.

The preoccupation is not better accounted for by Generalized Anxiety Disorder, Obsessive-Compulsive Disorder, Panic Disorder, a Major Depressive Episode, Separation Anxiety, or another Somatoform Disorder.

Criteria summarized from:

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, fourth edition. Washington, DC: American Psychiatric Association.

CONVERSION DISORDERS

Symptoms - Somatization Disorder

Kathryn Patricelli, MA

Somatization Disorder

Symptoms

A history of many physical complaints beginning before age 30 years that occur over a period of several years and result in treatment being sought or significant impairment in social, occupational, or other important areas of functioning.

Each of the following criteria must have been met, with individual symptoms occurring at any time during the course of the disturbance:

• four pain symptoms: a history of pain related to at least four different sites or functions (e.g., head, abdomen, back, joints, extremities, chest, rectum, during menstruation, during sexual intercourse, or during urination)
• two gastrointestinal symptoms: a history of at least two gastrointestinal symptoms other than pain (e.g., nausea, bloating, vomiting other than during pregnancy, diarrhea, or intolerance of several different foods)
• one sexual symptom: a history of at least one sexual or reproductive symptom other than pain (e.g., sexual indifference, erectile or ejaculatory dysfunction, irregular menses, excessive menstrual bleeding, vomiting throughout pregnancy)
• one pseudoneurological symptom: a history of at least one symptom or deficit suggesting a neurological condition not limited to pain (conversion symptoms such as impaired coordination or balance, paralysis or localized weakness, difficulty swallowing or lump in throat, aphonia, urinary retention, hallucinations, loss of touch or pain sensation, double vision, blindness, deafness, seizures; dissociative symptoms such as amnesia; or loss of consciousness other than fainting)

Either (1) or (2):

1. after appropriate investigation, each of the symptoms in Criterion_B cannot be fully explained by a known general medical condition or the direct effects of a substance (e.g., a drug of abuse, a medication)
2. when there is a related general medical condition, the physical complaints or resulting social or occupational impairment are in excess of what would be expected from the history, physical examination, or laboratory findings

The symptoms are not intentionally feigned or produced (as in Factitious Disorder or Malingering).

Criteria summarized from:

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, fourth edition. Washington, DC: American Psychiatric Association.

ABUSE

Recognizing Abuse

Kathryn Patricelli, MA

Abuse is not the easiest thing in the world to recognize, even if it is happening to you directly. Not everyone who is being abused understands that what they are experiencing is abuse. Some may recognize that something isn't right about how they are treated, but they may be afraid to speak up and name it as abuse for fear of retribution from their abuser. The following list describes various interactions that people might have that are examples of abuse. If one or more of these things is happening to you, there is very good chance that you are being abused.

• Being physically, sexually, or emotionally hurt and/or violated by your partner on a regular basis.
• Being called hurtful names and/or being put down by partner on a regular basis.
• Being controlled by partner. For instance, if your partner tells you that you are not allowed to have friends, leave the house without his or her permission, or tells you that you are not allowed to pursue your own goals, such as attending school or finding work.
• Becoming more withdrawn so that you do not spend much time with others who may clue in to the fact that abuse is happening to you.
• Finding yourself making excuses for your partner’s bad and harmful behavior (perhaps so that you won't have to accept the fact that abuse is happening).
• Recognizing that your relationship has a pattern or cycle in which something abusive occurs, you tell partner that you will not tolerate the abuse anymore, but then forgiving your partner when he or she apologizes.
• Blaming yourself for bad things your partner has done to you. For example, telling yourself that you are really difficult to live with so you deserve to be hit.
• Feeling trapped in your own home and being fearful when you know partner is coming home.

If you are a third party to a potentially abusive situation (suspected child abuse, domestic abuse or elder abuse), it may be difficult to know if abuse is happening in any direct manner. You might need to rely on circumstantial evidence to identify the abuse. The following list suggests things to look for that could be indicative of abuse.

• There are physical signs of injury, such as bruises, sores, burns, cuts, or black eyes. Such injuries may be hidden (e.g., behind sunglasses or with clothing)
• The victim makes implausible excuses for injuries or absences ("I fell down the stairs").
• The victim displays personality changes (angry, depressed, moody, defensive, etc.)
• The victim becomes withdrawn, or suddenly fearful.
• The victim becomes depressed, or more irritable or agitated than normal.
• The victim has difficulty sleeping at night, or may display excessive tiredness (can be a symptom of depression)
• The victim's appetite changes for better or worse. Weight loss or gain may occur (can be a symptom of depression).
• The victim's self-esteem lowers.
• The victim is distracted and has difficulty concentrating.
• The victim neglects hygiene (becomes smelly, goes unwashed; may be an attempt to ward off a sexual predator if a child, or as a consequence of depression).
• Changes are noted in the victim's personal appearance or in the appearance of his or her home or living environment.
• The victim complains of pain in the genital region (more common in children).
• For older children and adults, the victim 'acts out', becoming sexually promiscuous, and/or using drugs.
• Elders may display confusion

LEARNING DISORDERS

Symptoms of Specific Learning Disorder

Kathryn Patricelli, MA

Specific Learning Disorder is diagnosed when there are difficulties learning and using academics skills for at least 6 months in one or more of the following areas:

• Inaccurate or slow word reading - this can involve reading single words out loud incorrectly or reading them slowly and hesitantly, frequently guessing words because they aren't sure what it is, or having difficulty sounding out words.
• Difficulty understanding the meaning of what is read - in this category students may be able to accurate read the words, but they do not understand what they mean. They may be unable to track relationships that are being described or understand deeper meanings of the sentences and paragraphs beyond those of the individual words that are used.
• Difficulties with spelling - the student may add, leave out or substitute letters in words.
• Difficulties with written expression - the student has poor grammar and punctuation skills when writing, doesn't organize thoughts into paragraphs well, or writes ideas that are not clear.
• Difficulties mastering number sense, number facts or calculation - the student is unable to do basic math facts (adding, subtracting, multiplying or dividing), has to count on their fingers to come up with the answer, or gets lost in the middle of doing longer problems and is unable to solve the problem.
• Difficulties with mathematical reasoning - the student has difficulty applying math concepts or procedures to solve problems.

In addition to one or more on the above areas being affected, a few other items are required for a diagnosis including:

• The affected skills must be substantially below those expected for the child's age.
• The issues need to cause significant problems with academic performance.
• The problems begin during the school-age years, but may not become fully noticeable until academic demands become high, such as taking timed tests, completing long reports that have short deadlines, or very heavy homework levels.
• The learning disabilities are not the result of other issues, such as intellectual disabilities, uncorrected visual or hearing problems, other mental or neurological disorders, or inadequate teaching in those academic areas.

The academic areas and subskills that can be diagnosed as impaired include:

• Impairment in Reading - word reading accuracy; reading rate or fluency; reading comprehension.
• Impairment in Written Expression - spelling accuracy; grammar and punctuation accuracy; clarity or organization of written expression
• Impairment in Mathematics - number sense; memorization of arithmetic facts; accurate or fluent calculation; accurate math reasoning

Alternative Terms

• Dyslexia is another term that can used to refer to learning difficulties around accurate word recognition, poor decoding of words being used, and poor spelling.
• Dyscalculia is another term that is used to refer to a pattern of problems with processing numerical information, learning math facts, and doing accurate calculations.
• When either of these terms is used, the psychologist should also note other areas that are affected that don't fall specifically in these categories. For example, a child diagnosed with dyscalculia may also have trouble with word reasoning, or a child with dyslexia might also have poor math reasoning.

The 3 severity levels that can be diagnosed include:

• Mild - some difficulties exist in one or two academic areas, but are mild enough that the student may be able to compensate or function well with accommodations or support services.
• Moderate - difficulties in one or more academic areas and the individual is unlikely to become proficient without periods of intensive and specialized teaching.
• Severe - severe difficulties are affecting several academic areas and the individual is unlikely to learn those skills without ongoing intensive individualized and specialized teaching for most of the school years. Even with accommodations or services, the individual may not be able to complete all tasks efficiently.

Criteria summarized from:

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders, fifth edition. Washington, DC: American Psychiatric Association.

GRIEF & BEREAVEMENT ISSUES

Symptoms of Grief

Kathryn Patricelli, MA, edited by Mark Dombeck, Ph.D.

Though each person grieves in unique ways, there are common behavioral, emotional, and physical signs and symptoms that people who are grieving typically experience.

Physically, persons affected by grief may experience:

• Fatigue and exhaustion alternating with periods of high alertness and energy
• Temporary hearing loss or vision impairment (possibly associated with dissociation)
• Difficulty sleeping
• Disturbed appetite (either more appetite or less appetite than normal)
• Muscle tremors
• Chills and/or sweating
• Difficulty breathing or rapid respiration
• Increased heart rate or blood pressure
• Stomach and/or intestinal problems
• Nausea and/or dizziness

Mentally, persons affected by grief may experience:

• Confusion (memory, concentration, judgment and comprehension difficulties)
• Intrusion (unwanted thoughts, arousal, nightmares)
• Dissociation (feeling of detachment and unreality, disorientation, denial)

Emotionally, persons affected by grief may experience:

• Shock
• Fear, anxiety or apprehension
• Anger, irritability or agitation
• Guilt
• Numbness, remoteness, depression

POST-TRAUMATIC STRESS DISORDER

Post-Traumatic Stress Disorder (PTSD) Criteria

Jamie Marich, Ph.D., LPCC-S, LICDC-CS, RMT, edited by C. E. Zupanick, Psy.D.

This section is meant to be an informative guide only. It is not intended for self-diagnosis. These diagnostic summaries are only meant for educational purposes, not diagnostic ones. If you believe that these patterns of symptoms describe you or someone you love, seek out a professional opinion by a treatment provider who understands trauma.

Post-traumatic stress disorder (PTSD)

• Directly experiencing or witnessing a) death or threat of death; b) serious injury or threat of serious injury; or c) sexual violation;
• Intrusion symptoms - one symptom required;
• Avoidance symptoms - one symptom required;
• Negative thoughts and feelings - two symptoms required;
• Arousal and reactivity symptoms - two symptoms required;
• Duration of symptoms longer than one month;
• Functional impairment due to disturbances (examples of this can include being unable to work; limited productivity at work; problems in social situations or relationships; problems with health);
• Not attributed to another medical condition

POST-TRAUMATIC STRESS DISORDER

Acute Stress Disorder Criteria

Jamie Marich, Ph.D., LPCC-S, LICDC-CS, RMT, edited by C. E. Zupanick, Psy.D.

This section is meant to be an informative guide only. It is not intended for self-diagnosis. These diagnostic summaries are only meant for educational purposes, not diagnostic ones. If you believe that these patterns of symptoms describe you or someone you love, seek out a professional opinion by a treatment provider who understands trauma.

Acute Stress Disorder

• Often conceptualized as pre-PTSD, the symptoms are the same as PTSD but occur within the first month of exposure to a qualifying traumatic experience.
• There are a total of 14 symptoms in the five categories we reviewed for PTSD. A person needs any 9 of these 14 symptoms across the five categories:

1) intrusion symptoms,

2) negative mood,

3) dissociative symptoms,

4) avoidance symptoms, and

5) arousal symptoms.

• The symptoms cause clinically significant impairment (social or relationship problems, problems at work, home, or school).
• The implications for treatment and healing are similar to wound care. It is advantageous if trauma's impact can be treated as quickly as possible. With proper treatment and social support, coupled with good coping skills and resilience education, the likelihood of full-blown PTSD developing is greatly diminished.

OBSESSIVE-COMPULSIVE SPECTRUM DISORDERS

Diagnosis: The Signs and Symptoms of Obsessive-Compulsive Disorder (OCD)

Matthew D. Jacofsky, Psy.D., Melanie T. Santos, Psy.D., Sony Khemlani-Patel, Ph.D. & Fugen Neziroglu, Ph.D. of the Bio Behavioral Institute, edited by C. E. Zupanick, Psy.D.

As the name implies, the obsessive-compulsive disorder (OCD) is the kingpin of the entire category of disorders called obsessive-compulsive and related disorders. Obsessions are repetitive and distressing thoughts, urges, or imagery that are experienced as uncontrollable. Compulsions are repetitive behaviors or mental acts that a person feels driven to perform in response to obsessions. These obsessions and compulsions are at times consuming (an hour or more per day). They create significant distress and/or interfere with a person's functioning.

Ordinarily, obsessional thoughts, images, or impulses are not about typical, everyday things. Common obsessional themes are:

• extreme and unrealistic concerns about contamination, and/or need for cleanliness;
• repeated and excessive doubts, such as wondering if a door was left unlocked, or if a coffee pot was turned off;
• the need to have things in a precise and particular order or arrangement (with intense distress or distractions if this order or arrangement is disturbed);
• aggressive or horrific impulses, such as a desire to harm one's child; and
• disturbing sexual imagery, such as intrusive pornographic imagery.

These are the most common types of obsessions. However, any distressing, repetitive, uncontrollable, and unwanted thought can form an obsession.

Obsessions are not the same as hallucinations, which are a hallmark symptom of several other, rather severe, mental disorders (psychotic disorders). When someone is experiencing a hallucination, they are unaware that what they are experiencing is not real and a creation of their own mind. In contrast, people who experience obsessions recognize that the obsessions are generated by their own mind. This is true, even for people with limited insight.

People with OCD try to ignore or neutralize these intrusive thoughts, images, or impulses. In other words, they attempt to counteract or block these distressing and repetitive thoughts. One way people try to block or neutralize obsessions is with compulsions. Compulsions are recurring behaviors (such as repeatedly checking appliances or repeatedly washing hands) or repetitive mental acts (such as counting or praying) that an individual feels they must do in response to an obsession.

Compulsions serve to avoid or reduce distress. In some cases, a person may believe they must perform compulsive acts in order to prevent something terrible from happening. For example, a person may touch things only after they have all been bleached. They believe they must perform this act in order to prevent disease.

Children's OCD symptoms are similar to adults. However, children may not ask for help. Therefore, it becomes their caregivers' responsibility to identify these symptoms and seek treatment. While an adult may be able to tell you their rationale for the compulsive act ("I'm washing my hands so I don't contract HIV"), a child may not be able to articulate this. Even though children may be unable explain the reason for their compulsive behavior, they may still try to minimize their compulsions in front of others.

The diagnosis of OCD includes an insight specifier to further refine the diagnosis. While it is true that obsessions and compulsions are based on inaccurate or irrational beliefs, people differ in terms of whether they recognize this fact. In other words, some people readily recognize and accept that obsessions and are not sensible. Nonetheless, this insight is insufficient to prevent the obsessions and compulsions. Other people lack this insight. They firmly cling to their distorted beliefs, despite evidence that refutes the validity of such beliefs. This lack of insight is important with respect to treatment. In general, people with poor or absent insight have a poorer prognosis for a full and complete recovery. However, the degree of insight can be quite variable. In one moment, a person may be well aware their beliefs are irrational. Later, when directly faced with a fearful situation, this insight may vanish completely.

There are three insight specifiers: 1) good/fair, 2) poor, or 3) absent/delusional. An insight specifier rates a person's degree of insight about their disorder-related beliefs. For instance, some people realize that checking the locks, dozens of times throughout the day, is unlikely to affect whether or not a burglary occurs. This indicates good/fair insight. Someone else may believe that without this degree of vigilance a burglary is nearly certain to occur. This indicates poor insight. A small minority of people are absolutely convinced a burglary is certain to occur without rigorous checking of locks. These people demonstrate absent/delusional insight.

The presence of absent/delusional insight requires very careful diagnostic evaluation. Delusional thoughts are also a symptom of another category of rather severe disorders, called psychotic disorders. Therefore, is very important that the absent/delusional insight in an OCRD is not misdiagnosed as psychotic disorder merely because of delusional beliefs. Proper diagnosis is essential to receiving the right treatment. For example, the medications used to treat psychotic disorders are very different than for OCRDs. If the symptoms of OCRDs are misdiagnosed as a psychotic disorder, a person might receive the wrong kind of medication.

About 30% of people with OCD will also have a tic disorder at some point in their lives. For this reason, OCD has a tic specifier. This diagnostic distinction is made because people with tic disorder have different presentations of OCD than those who never had a tic disorder. Tic disorder is more common in males with childhood onset OCD (APA, 2013).

ADDICTIONS: ALCOHOL AND SUBSTANCE ABUSE

Symptoms - Alcohol or Substance Abuse

DSM-IV-TR (APA)

The Diagnostic and Statistical Manual of Mental Disorders (currently the fourth edition, text-revision) is the standard reference against which all mental disorders (substance use disorders included) are made. The criteria involved for making a formal Substance Abuse diagnosis is as follows:

The patient shows . . .A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occuring in a 12 month period:

• 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 the household).
• 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)
• Recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct)
• Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights)
• The symptoms have never met the criteria for Substance Dependence for this class of substance.

Only a doctor can make a formal diagnosis of substance abuse or substance dependance.

Criteria summarized from:

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders, fourth edition, text revision Washington, DC: American Psychiatric Association.

ADDICTIONS: ALCOHOL AND SUBSTANCE ABUSE

Symptoms - Alcohol or Substance Dependence

DSM-IV-TR (APA)

The Diagnostic and Statistical Manual of Mental Disorders (currently the fourth edition, text-revision) is the standard reference against which all mental disorders (substance use disorders included) are made. The criteria involved for making a formal Substance Dependence diagnosis is as follows:

• The patient shows . . . A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:
• Tolerance, as defined by either of the following:

- a need for markedly increased amounts of the substance to achieve intoxication or desired effect

- markedly diminished effect with continued use of the same amount of the substance

• Withdrawal, as manifested by either of the following:

- The characteristic withdrawal syndrome for the substance

- The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms

• The substance is often taken in larger amounts or over a longer period than was intended
• There is a persistent desire or unsuccessful efforts to cut down or control substance use
• A great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain-smoking), or recover from its effects
• Important social, occupational, or recreational activities are given up or reduced because of substance use
• The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption)

When a diagnosis of Substance Dependence is made, the diagnosing doctor must also specifiy whether or not the patient is Physiologically Dependent.  Physiological dependence, in this case means that there is evidence of tolerance or withdrawal (as defined in the first two criteria).  Note that it is possible to be diagnosed with Substance Dependence without displaying either tolerance or withdrawal. 

Note that only a doctor can make a formal diagnosis of substance abuse or substance dependance.

Criteria sumarized from:

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders, fourth edition. text revision Washington, DC: American Psychiatric Association.

AGING & GERIATRICS

Symptoms of Alzheimer's Disease

Carrie Hill, Ph.D. and Natalie Reiss, Ph.D.

Alzheimer's disease is difficult to diagnose because the only sure way to identify the disease is to analyze brain tissue. Taking brain tissue from a person can only be done after the person has already died. Most people are not willing to wait until someone has died to find out if they actually had Alzheimer's disease. Therefore, the diagnosis is often made on the results of many tests including:

• brain scans
• cognitive testing (often referred to as neuropsychological testing) where a person's memory, language skills, and other mental functions are evaluated
• the reports of the person or people close to the person about any changes in their thinking such as memory loss.

The Diagnostic and Statistical Manual of Mental Disorders - Fifth Edition (DSM-5) is the technical manual used by mental health care clinicians to diagnose mental disorders. The DSM-5 upgraded the diagnosis for dementia that was used in previous versions. First, a person must meet the diagnostic criteria (diagnostic conditions or symptoms) for Mild Neurocognitive Disorder or Major Neurocognitive Disorder.

A person with Mild Neurocognitive Disorder:

• Would display a decline in their thinking that is based on either:

- The report of someone that knows the person very well that indicates that the person's thinking abilities have slowly declined. This could be a family member, a very close friend, or even a doctor.

- Having demonstrated mild impairments on neuropsychological tests or other similar types of assessments.

• The person's problems with thinking do not seriously interfere with their activities, but results in them using more energy or intentionally working harder to perform their daily activities.

A person with Major Neurocognitive Disorder would also demonstrate a decline in their thinking abilities based on a report from someone else or on formal neuropsychological testing. However, the problems with their thinking significantly interfere with their daily functioning.

A diagnosis of either Mild or Major Neurocognitive Disorder can only be made if the person's symptoms cannot be better explained by some other mental disorder such as depression or schizophrenia. The symptoms also do not happen only when the person is delirious (a temporary state of confusion that can be caused by many issues such as having an illness, being under the influence of medications or drugs, having a metabolic imbalance, etc.).

Neurocognitive disorders can have many different causes. When a diagnosis of either a Mild Neurocognitive Disorder or Major Neurocognitive Disorder is believed to be due to Alzheimer's disease the person:

• Must first meet the diagnosis for either Mild or Major Neurocognitive Disorder.
• Have displayed a gradual progression in one or more areas of cognition or thinking:

- For mild neurocognitive disorder at least one area of thinking must be impaired.

- For major neurocognitive disorder at least two areas of thinking must be impaired.

People diagnosed with Mild Neurocognitive Disorder can also be diagnosed with:

• Probable Alzheimer's disease: If there is evidence that the person has genetic factors that can lead to Alzheimer's disease from genetic testing or has family members who are diagnosed with Alzheimer's disease.
• Possible Alzheimer's disease: If there is no genetic evidence but there is evidence of a decline in the person's learning and memory abilities.The decline in thinking is gradual and steady. There is no evidence that other factors such as a stroke, other types of dementia, or other conditions can explain the decline in the person's memory and learning.

People diagnosed with Major Neurocognitive Disorder can also be diagnosed with:

Probable Alzheimer's disease: If the person has either:

• Evidence of a genetic factor that contributes to Alzheimer's disease such as a family history of Alzheimer's disease or the results of genetic testing.
• Or all of the following:

- Evidence of a decline in their learning and memory and at least one other area of cognition based on neuropsychological testing or a very detailed history.

- A steady, gradual, and progressive decline in memory and other areas of cognition.

- No evidence of other factors that can cause dementia such as stroke or other neurological conditions.

- If the above conditions are not met, then the person with Major Neurocognitive Disorder would be diagnosed with Possible Alzheimer's disease.

Major Neurocognitive Disorder is then further broken down into levels of severity:

Mild when the person's difficulties result in them having problems with what are referred to as instrumental activities of daily living (IADLs). These are basic skills that people need to live independently such as being able to pay their bills, doing housework, shopping, preparing meals, etc.

Moderate when the person's difficulties result in them having problems performing basic activities of daily living (BADLs or sometimes just ADLs). These skills represent more basic skills such as washing, dressing, etc.

Severe when the person's difficulties result in them being fully dependent on others to help them perform their basic and instrumental activities of daily living.

The diagnosis of Alzheimer's disease requires that a person has demonstrated a decline or drop in their ability to learn new information and remember things. Memory loss is the major sign that a person may be developing Alzheimer's disease. The DSM-5 also refers to other cognitive or thinking abilities that also decline in people that have the disease. Typically, memory is the first area of thinking that demonstrates a decline, but other areas of thinking also decline and can be identified in the diagnosis. These areas include:

Language Abilities: Clinicians often refer to the deterioration of language abilities as the development of aphasia. Different language abilities can be affected in Alzheimer's disease. One of the most frequent areas affected is the person's ability to name familiar objects (this is known as agnosia). Another language skill that is often affected is the person's ability to understand complex commands or to repeat phrases said to them. People with Alzheimer's disease often demonstrate "word finding difficulties" where they are trying to think of a word in conversation but cannot find it. These difficulties happen on occasion in people without Alzheimer's disease. However, people affected with the disorder display them far more frequently and their ability to function normally is significantly affected by these problems.

Attention: People affected with Alzheimer's disease often display difficulties with attention, particularly with what is referred to as complex attention. This ability involves being able to shift back and forth between objects of focus. It can also involve maintaining one's focus for an extended period of time. Again, people without Alzheimer's disease often display mild issues with these abilities. However, people with the disease display more severe and long-term issues with these abilities.

Visual spatial skills: Visual spatial abilities (also known as visuospatial abilities) refer to how a person can understand the relationships between objects in the environment and how they can view or imagine objects from different perspectives. For example, tests of these abilities often require people to copy designs, put together blocks in a specific order, or match geometric figures. These skills are used in everyday life to help us move through our environment. We use them to estimate distances between ourselves and objects or between different objects (such as when walking or driving a car). We also use them to follow instructions and put things together. They can also help us understand differences and similarities between objects.

Executive functions: This area of abilities is concerned with planning, judgment, and abstract thinking. Abstract thinking involves being able to think about things that are not actually present in the real world or to think in symbolic terms. People with Alzheimer's disease often demonstrate issues with planning or organizing activities or events, even activities that they once routinely performed.

Apraxia: This area of functioning involves the ability to perform well learned physical tasks. People with Alzheimer's disease often have difficulty performing tasks that they once were able to perform without even thinking about doing them. This could include dressing themselves, bathing, washing their clothes, tying their shoes, etc.

Neuropsychological tests can determine if a person has declined in these cognitive or thinking abilities. The results of these tests can help to diagnose Alzheimer's disease. In addition to the results of the tests, the reports of other people who are close to the person can be used. The reports can demonstrate that the person's cognitive abilities have gradually and slowly declined over time, which can also assist with the diagnosis. Clinicians prefer both the results of testing and the reports of the person or other people over either of these alone in making the diagnosis. The more evidence the clinician can gather, the more confident they can be in their ability to make the right decision as to why the person is experiencing problems with their thinking and get them treatment.

In general, the progression of Alzheimer's disease can be very rapid or very slow and research has indicated that it can take from between one to 20 years to fully progress. The average length of time that a person will have Alzheimer's disease from when it is first diagnosed until they die is about eight years. However, there is quite a bit of variation from person to person.