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17 4 4 F R I D A Y S 2 - 5 P MD R . G R E E N O

SNOW DAY MAKE-UPNEUROCOGNITIVE DISORDERS;

DISSOCIATIVE DISORDERS; FEEDING & EATING DISORDERS

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NEUROCOGNITIVE DISORDERS

•In the DSM IV-TR this section was known as Delirium, Dementia, and Amnesic and Other Cognitive Disorders•In DSM-5 name/organization change but many of the diagnoses were renamed but correspond to former diagnoses•Hallmarks

Etiology and can be determinedDisorders updated due to extensive research

•Be familiar with tables that start on page 593

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DELIRIUM

A. Disturbance in attention (focus, sustain, shift attention) and awareness (reduced orientation to environment).

B. Disturbance develops over a short period of time (hours to days)—difference in baseline and there is likely fluctuation throughout course of the day

C. Disturbance in cognition (i.e., memory, disorientation, language)

D. Disturbances from criteria A and C are not better explained by another preexisting or evolving neurological disorder or context of a coma (or reduced level of arousal)

E. Evidence from the history, physical examination, or laboratory findings that the disturbance is a direct physiological consequences of another medical condition, subs intoxication or withdrawal, or exposure to toxin, or due to multiple etiologies

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WHAT IS DELIRIUM?

• Disturbance of consciousness and a change in cognitive that develops over a short period of time (hours to days). There is evidence from the history, physical examination, or lab tests that the delirium is the direct physiological result of a general medical condition, substance intoxication/withdrawal, use of a medication, toxin exposure, or combination of these factors.

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WHAT DOES DELIRIUM LOOK LIKE?

• Depends on general medical condition• Not aware of the environment (Criterion A)• Change in Cognition (Criterion B)—Quick change in mental states• Functioning, inattention, perceptual disturbances, and fluctuation of symptoms• Can fluctuate during the course of the day• Reduced clarity of awareness of the environment—changes in consciousness and

awareness• Inability to focus, sustain, or shift attention is impaired• Repeat questions b/c attention wanders or person is perseverating on something• Changes in alertness (usually more in the am)• Changes in sleep • Decreased short-term memory and recall• Disrupted or wandering attention• Disorganized thinking (speech, can’t stop speech patterns or behaviors)—easily distracted• Emotional or personality changes• Psychomotor restlessness• Memory—huge concern (ask them to remember a list of objects), disoriented to time/place• Physical sensations• Hallucinations, delusions, language disturbances, and agitation

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WHAT DOES DELIRIUM LOOK LIKE?

• Common Exams:• Blood chemistry• Neurological examination• Toxicology screens• Head CT and/or MRI• Living Functioning• MSE• Urinalysis

• Common causes:• Alcohol or drug use• Alcohol or drug withdrawal• Infections• Poisons• Surgery

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HOW DO SOCIAL WORKERS DIAGNOSIS DELIRIUM?

Social Workers can do a MSE (Mental Status Exam) but also need to do this in conjunction with other professionals and procedures: • Physical Exam• Medical History• Mental Status Exam (2nd time)• Adequate History

-should include perspective from the family/friend• Imaging Procedures (i.e., CT scans, MRIs)-

sometimes work• Lab Tests

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DELIRIUM

• Prognosis-if the underlying disorder is found quickly then the

greater the likelihood of full recovery-can lead to detrimental outcomes-in medically ill or elderly generally there are more

detrimental consequences• Treatment-Depends on underlying medical condition-What does Social Work intervention look like?

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DELIRIUM

• Specify whether:• Substance intoxication delirium• Substance withdrawal delirium• Medication-induced delirium

• Note codes on page 596 and 597• 293.0 Delirium due to multiple etiologies• 293.0 Delirium due to another medical condition• Additional specifiers page 597 and 598

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DELIRIUM

• Differential diagnosis—How distinguish?• Psychotic Disorders (have to distinguish the

hallucinations, delusions, language disturbances, and agitation)

• Acute Stress Disorder: precipitated by traumatic event• Malingering and factitious disorder: etiology for delirium• Other neurocognitive Disorders: can be difficult with

dementia, look a the acute onset of delirium vs. the typical gradual of dementia

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MAJOR NEUROCOGNITIVE DISORDERS

A. Significant decline from previous level of performance in one or more cognitive domains (complex attention, executive function, learning and memory, perceptual-motor, or social cognition)

B. Cognitive deficits interfere with independence in everyday activities

C. Cognitive deficits do not occur exclusively in the context of delirium

D. Cognitive deficits not better explained by another mental disorder

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MAJOR NEUROCOGNITIVE DISORDERS

• See specifications—page 603

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MILD NEUROCOGNITIVE DISORDER

A. Modest cognitive decline from a pervious level of performance in one or more cognitive domains (complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition) based on:

1. Concern2. modest impairment in performance

B. Cognitive Deficits DO NOT interfere with capacity for independence in everyday activities

C. Cognitive deficits do not occur exclusively during deliriumD. Cognitive deficits are not better explained by another

mental disorderNote specifiers page 605

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OTHER HALLMARKS

• Depression (particularly at beginning stages)• Agitation• Sleep disturbance• Apathy (particularly with Alzheimer’s Disease)—

lack of goal directed behavior• Emotional responsiveness• Loss of previous interests• Other behavioral symptoms• Wandering, disinhibition, hoarding—when more than one

is present give specifier of “with behavioral symptoms”

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DISSOCIATIVE DISORDERS

• Hallmarks• Disruption of consciousness, memory, identity,

emotion, perception, body representation, motor control, and behavior.• Dissociative Identity Disorder• Dissociative Amnesia• Depersonalization/Derealization Disorder• Other Specified and Unspecified Dissociative Identify

Disorder

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DISSOCIATIVE DISORDERS

• Frequently occur after trauma• Close relationships between Dissociative

Disorders and Trauma related disorders

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DISSOCIATIVE IDENTITY DISORDER 300.14

A. Disruption of identity characterized by 2 or more distinct personality states

B. Recurrent gaps in recall, personal information, and traumatic events that inconsistent with ordinary forgetting

C. Symptoms cause clinically significant distress or impairment in social, occupational, or other areas of functioning

D. Disturbance is not a normal part of accepted cultural or religious practice

E. The symptoms are not attributable to physiological effects of a substance or another medical condition

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DISSOCIATIVE AMNESIA 300.12

A. Inability to recall important autobiographical information, usually of a traumatic or stressful nature, that is inconsistent with ordinary forgetting

B. Symptoms cause clinically significant distress or impairment in social, occupational. Or other important areas of functioning

C. Disturbance not attributable to effects of a substance, neurological or other medical condition

D. Disturbance is not better explained by DID, PTSD, Acute stress disorder, somatic symptom disorder, or major or mild neurological disorder

Coding for Dissociate Fugue: purposeful travel or bewildered wandering that is associated with amnesia for identify or for other important auto biographical information

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DEPERSONALIZATION/DEREALIZATION DISORDER 300.6

A. Persistent or recurrent experiences of depersonalization, derealization, or both:

Depersonalization: Experiences of unreality, detachment, or being an outside observer with respect to one’s thoughts, feelings, sensations, body, or actions (perceptual alterations, distorted sense of time, unreal, emotional and/or physical numbing)

Derealization: experiences of unreality or detachment with respect to surroundings (unreal, dreamlike, foggy, lifeless)

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DEPERSONALIZATION/DEREALIZATION DISORDER 300.6

B. During depersonalization or derealization reality testing remains intactC. Symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioningD. Disturbance is not attributable to the physiological effects of a substance or another medical conditionE. Disturbance not better explained by another mental disorder

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FEEDING & EATING DISORDERS

• Hallmarks• Disturbance of eating or eating-related behavior that

results in altered consumption or absorption of food

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FEEDING & EATING DISORDERS

• Pica• Rumination Disorder• Avoidant/Restrictive Food Intake Disorder• Anorexia Nervosa• Bulimia Nervosa• Binge-Eating Disorder• Other/Unspecified Feeding or Eating Disorders

Mutually Exclusiv

e

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AVOIDANT/RESTRICTIVE FOOD INTAKE DISORDER

A. Eating disturbance as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of:

1. Significant weight loss2. Significant nutritional deficiency3. Dependence on enteral feeding or oral nutritional supplements4. Marked interference with psychosocial functioning

B. Not explained by associated culturally sanctioned practiceC. Eating disturbance does not occur exclusively during anorexia

nervosa or bulimia nervosa, and NO evidence of experience in disturbance for one’s body weight or shape

D. Not attributable to concurrent medical condition or another mental disorder

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AVOIDANT/RESTRICTIVE FOOD INTAKE DISORDER

• Displaces feeding disorder of infancy or early childhood from DSM IV• Lack of interest in food—not body weight • Restriction may be based on color, smell, texture,

temperature, taste, appearance• Fear of choking• May persistent into adulthood• Currently insufficient evidence to suggest linking

to eating disorder

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ANOREXIA NERVOSA 307.1

• A. Restriction of energy intake relative to requirements, leading to significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight definition

• B. Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though they are at a significantly low weight

• C. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight

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• Restricting type: During the last 3 months person has NOT regularly engaged in binge-eating or purging behavior. Weight loss is accomplished through dieting, fasting, and/or excessive exercise.

• Binge-Eating/Purging Type: During the last 3 months person regularly engaged in binge-eating or purging behavior• Code for most recent episode

• Specify if: In partial remission or in full remission• Specify current severity: mild, moderate, severe, extreme

• HBO Documentary THIN• http://www.youtube.com/watch?v=3Git2_X74_c

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• Suicide Risk—elevated• Health consequences due to anorexia• More prominent in post-industrialized, high

income countries

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307.51 BULIMIA NERVOSA

Essential feature is binge eating and inappropriate compensatory methods to prevent weight gain

Diagnostic Criteria:A: Recurrent episode of binge eating

a. eating in a discrete period of time an amount of food that is larger than what most would eatb. Sense of a lack of control over eating during an episode

B. Recurrent inappropriate compensatory behavior in order to prevent weight gain

C. Binge eating and inappropriate compensatory behavior occur at least twice a week for 3 months

D. Self-evaluation is unduly influenced by body shape and weightE. Disturbance does not occur during episode of Anorexia Nervosa

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BULIMIA NERVOSA 307.51

• Specify if : In partial remission or in full remission• Specify current severity based on frequency of

inappropriate compensatory behaviors: mild, moderate, severe, extreme

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BINGE-EATING DISORDER 307.51

A. Recurrent episodes of binge eating. Characterized by:a. eating in a discrete period of time an amount of food that is

larger than what most would eatb. Sense of a lack of control over eating during an episodeB. The binge-eating episodes are associated with three or more

of the following:1. Eating rapidly2. Eating until feeling uncomfortably full3. Eating large amounts when not hungry4. Eating alone b/c of embarrassment by how much one is eating5. Feeling disgusted with oneself, depressed, or guilty afterward

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C. Marked distress regarding binge eating is present

D. Binge eating occurs on average at least once a week for 3 months

E. Binge eating is not associated with the recurrent use of inappropriate compensatory behavior (like bulimia) and does not occur during the course of bulimia or anorexia

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• Specify if: partial or full remission• Specify current severity based on frequency of

binge eating episodes; mild, moderate, severe, extreme

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TREATMENT FOR EATING DISORDERS

• Must work with medical doctor and someone who specializes in the treatment of Eating Disorders (hospitalization may be necessary)

• Often use multidisplinary team approach

• Medication Management• Family Therapy• Psychotherapy (other

approaches we have discussed in class)• Cognitive• Cognitive-Behavioral

• Behavioral• Family Therapy or

Couples• Psychosocial• Psychoanalysis• EMDR• Functional Therapy• Psycho educational

Therapy• Intervention

Programs/Community Support

• Addictions/Substance Treatment (if applicable)

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