This website, designed for my patients,
should not replace the advice provided
by
your own health care provider.
Mission
My mission is to enhance patient care by providing information on psychiatric disorders and their treatment
Diagnostic & Statistical Manual of Mental Disorders, 5th Edition
(DSM-5)
Every diagnosis explained on this website follows the DSM-5 guidelines published by the American Psychiatric Association in 2013. This site uses mnemonics, or memory aids, to describe symptoms of psychiatric conditions.
Major Depressive Disorder (MDD).
A diagnosis of MDD is made when an individual has 5 of 9 symptoms. The 9 symptoms are represented by the phrase “Face Is Sad”, each letter representing 1 symptom:
F: Fatigue or lack of energy
A: Agitation (or retardation)
C: Concentration loss or indecisiveness
E: Esteem loss (feeling worthless) or excessive guilt
I: Interest loss or loss of pleasure
S: Sleep issues (too little or too much)
S: Suicidal thoughts (with or without a suicidal plan)
A: Appetite & weight change
D: Depressed Mood
The symptoms must be present most of the day and nearly every day during the same 2-week period.
At least one of the 9 symptoms must be depressed mood or loss of interest.
The symptoms cause impairment in functioning (socially, occupationally, etc.)
Treatment of MDD
Treatment begins after your condition has been carefully assessed by your family doctor or mental health care provider. Mild cases of MDD often respond to psychotherapy (talk therapy). Moderate to severe cases of MDD may require treatment with antidepressant medication.
Monitoring Your Mood
The Patient Health Questionnaire (PHQ-9) consists of 9 questions, each question evaluating one of the 9 symptoms of major depressive disorder (MDD). PHQ scores are interpreted as follows:
Cutpoints of 5, 10, 15 and 20 represent the thresholds for mild, moderate, moderately severe and severe depression respectively.
The Beck Depression Inventory is also completed by the patient. Rating scales do not replace clinical care but enhance screening and monitoring of mood. The clinician is expected to rule out physical causes of depression, normal bereavement and history of a manic episode.
The Mood Tracker helps patients to monitor mood on a daily basis. The record can help to clarify diagnosis and to monitor treatment response.
Impairment of Function
Almost all psychiatric disorders have 3 diagnostic components. Firstly, there are required symptoms (e.g. 9 symptoms in Major Depression). Secondly, symptoms must be present for a minimum period of time (e.g. 2 weeks in Major Depression). Thirdly, there must be impairment of functioning in major areas of the patient’s life (e.g. at work, at school, socially, etc). One way to measure the degree of impaired functioning is to ask the patient to complete the 12-item disability assessment questionnaire (linked below) published by the World Health Organization.
Persistent Depressive Disorder (Chronic MDD)
The essential feature is a depressed mood that occurs for most of the day, for more days than not, for at least 2 years. Criteria for MDD may be continuously present for 2 years. If the symptoms of MDD are present for 2 years the patient is given a diagnosis of MDD and Persistent Depressive Disorder.
Unspecified Depressive Disorder
Depression is present with impaired functioning BUT the patient has insufficient symptoms for a diagnosis of MDD. This diagnosis may be used when there is insufficient information (e.g. in emergency room settings).
Seasonal Affective Disorder
When episodes of major depression start and stop at characteristic times of the year (e.g. in the fall or winter) the appropriate diagnosis is Recurrent Major Depressive Disorder with Seasonal Pattern. This condition is sometimes referred to as Seasonal Affective Disorder. Full recovery also occurs at a characteristic time of the year (e.g. depression disappears in the spring). In this disorder, during the past 2 years, two major depressive episodes have occurred that demonstrate the temporal seasonal relationships defined above and no nonseasonal major depressive episodes have occurred during the same period. Seasonal major depressive episodes substantially outnumber the nonseasonal major depressive episodes that may have occurred over the individual’s lifetime.
Seasonal Affective Disorder affects 2-3% of the population. Another 15% have a milder form of the condition known as the “winter blues”. Patients feel their mood plummeting as the clocks change or the days get shorter. Like other forms of depression, SAD can be very debilitating making it difficult to function normally at work, school or home. Patients with SAD often crave carbohydrates and gain weight. There is also a tendency to sleep more.
While a definitive cause of SAD is not known, research suggests that less sunlight in the winter disrupts our sleeping and waking patterns. It can also result in a reduction of serotonin, a chemical that affects our moods.
Risk factors include gender (far more women than men are affected), age (SAD is more prevalent as we get older, with a peak onset at about 40 years of age) and a family history of the disorder. The incidence of SAD is also higher in northern countries like Canada that experience fewer hours of sunshine annually.
TREATMENT: Regular exercise is key, as is spending time out in the sunshine. If possible, take a walk in the middle of the day. Improve light levels in your home and workplace. When symptoms are significant, daily light therapy with a special light box (see link above) often reduces symptoms. When all else fails, antidepressant medications have proven to be effective in the treatment of SAD.
Bipolar Affective Disorder (BAD).
Bipolar Affective Disorder (previously called manic depression) is diagnosed when periods of depression alternate with periods of elevated, expansive or very irritable mood. The elevated or “high” moods are called the manic or hypomanic phases. Manic phases last at least 7 days while hypomanic phases (the milder form) last at least 4 days. In MANIA there is marked impairment of functioning while in HYPOMANIA function is less impaired. During the elevated mood phase a patient will have at least 3 of 7 symptoms. The 7 symptoms are listed in the mnemonic IMPAIRED: [Canadian Journal of Psychiatry 1998;43(4):422]
IMpulsivity (sexual indiscretions, driving & spending recklessly)
Pressured Speech (speaking very quickly)
Activity Increase
Insomnia (decreased need for sleep)
Racing Thoughts
Esteem elevation
Distractibility
The more serious form of BAD with manic episodes is called Bipolar disorder type I while the milder form with hypomanic episodes is called Bipolar disorder type II. In the United States 60% of patients experience the onset of BAD before the age of 19. About 50% of bipolar patients present with a depressive episode.
Around 20% of bipolar patients are “rapid cyclers” with at least 4 episodes of either pole (i.e. depression or mania/hypomania) within 1 year.
Mood Disorder Questionnaire (MDQ)
The MDQ is a questionnaire used to detect possible cases of Bipolar Disorder. The MDQ is for screening purposes only and is not to be used as a diagnostic tool. A positive screen should be followed by a comprehensive evaluation by your family physician or a psychiatrist. “Yes” to 7 or more of the 13 items in question 1 & “Yes” to question number 2 & “Moderate Problem” or “Serious Problem” to question 3 is a positive screen suggesting further evaluation.
Adjustment Disorder
Adjustment disorder is diagnosed when emotional or behavioral symptoms develop within 3 months following the onset of a stressor. The distress is out of proportion to the stressor and interferes with functioning. Once the stressor or its consequences have terminated, symptoms terminate within 6 months. In a hospital psychiatric consultation setting, it is often the most common diagnosis, frequently reaching 50%.
Anxiety Disorders:
Anxiety is a normal part of everyday life but when anxiety becomes intense and persistent and interferes with your functioning, you may be suffering with an anxiety DISORDER. There are several types of anxiety disorder including Generalized Anxiety, Social Anxiety, Panic Disorder and OCD. Treatment includes education, psychotherapy, medication and lifestyle changes. Relaxation therapy, mindfulness and focusing on and slowing down breathing can reduce anxiety and prevent panic attacks.
I recommend The Anxiety & Phobia Workbook by Edmund J Bourne for patients suffering from any type of anxiety disorder. For therapists and physicians wishing to increase their understanding of the neurobiology of anxiety and fear, I recommend The Emotional Brain by Joseph LeDoux.
Social Anxiety Disorder
Social Anxiety Disorder is a common condition with onset between 8 & 15 years in 75% of cases. Symptoms are recognized by the mnemonic FAINT. [Berber M.J. Canadian Journal of Psychiatry 2004;49(9):645]
F: Fear of 1 or more social or performance situations in which the person feels scrutinized, humiliated or embarrassed
A: Anxiety when exposed to the feared situation and Avoidance of the situation
I: Insight into the unreasonableness of the fear and Interference in functioning
N: Not due to medication, drug abuse or a medical condition
T: Timing: If under 18 years old, symptoms have been present for at least 6 months
Treatment of Social Anxiety Disorder includes Cognitive Behavioral Therapy (CBT). “The Shyness & Social Anxiety Workbook” by Antony & Swinson is an excellent starting point in treatment. I recommend this book to ALL my patients with Social Anxiety Disorder.
Social Anxiety Disorder, also called Social Phobia, can be detected using the Social Phobia Inventory (SPIN) available below with kind permission from Dr. Jonathan Davidson.
Panic Disorder
Panic DISORDER features at least one Panic Attack (see below) followed by: 1. Concern about more attacks, 2. Concern about the consequences of attacks (e.g. heart attack) and 3. Change in behavior related to the attacks (e.g. refusal to go to the mall).
A Panic ATTACK is a clear-cut period of intense fear or discomfort, in which 4 or more of the following 13 symptoms develop abruptly, reaching a peak within 10 minutes. The symptoms are remembered by the phrase STUDENTS FEAR the C. [Berber MJ. American Journal of Psychiatry 1997;154(3):438]
Sweating
Trembling
Unsteadiness
Depersonalization
Excessive Heart Rate (palpitations)
Nausea
Tingling
Shortness of Breath (or smothering)
Fear of Losing Control or Going Crazy
Fear of Dying
Chills (or hot flushes)
Chest Pain
Choking
Treatments for Panic Disorder include CBT, relaxation and breathing techniques and various medications. Check out the downloadable CBT book and the relaxation YouTube links under the “Psychotherapy” tab.
Generalized Anxiety Disorder (GAD)
9% will develop GAD during their lifetime, the essential feature being excessive worry and anxiety about a number of events of activities. GAD is diagnosed when there are 3 or more of 6 symptoms in addition to the core worry and anxiety. The GAD symptoms are memorized using the mnemonic WATCHERS. [Berber MJ. Journal of Clinical Psychiatry 2000;61(6):447]
W: Worry and Anxiety for at least 6 months with impaired function
A:
T: Tension in neck & shoulder muscles
C: Concentration problems (mind goes blank)
H: Hyper-agitation (irritability)
E: Energy Loss (or fatigue)
R: Restlessness (feeling on edge)
S: Sleep Disturbance (insomnia)
Post Traumatic Stress Disorder (PTSD)
The symptoms of PTSD are reflected in the mnemonic TRAUMA. [Khouzam H. Western Journal of Medicine 2001;174(6):424]
Traumatic Event - associated with helplessness, fear & horror
Re-experiencing the trauma - flashbacks, nightmares
Avoidance - of anything associated with the trauma
Unable to function (socially, occupationally, interpersonally)
Month - or more of symptoms
Arousal is increased - hypervigilance, startle reaction, irritability
Borderline Personality Disorder
Borderline personality disorder (BPD) is defined as a pattern of unstable personal relationships, self-image, moods, and marked impulsivity.
Borderline personality disorder occurs in about 2% to 3% of the population and is by far the most common personality disorder in clinical settings. It occurs in 11% of patients seen in outpatient mental health clinics and in 19% of psychiatric inpatients. 5, or more, of 9 symptoms suggests the presence of the disorder.
The mnemonic PRAISE helps detect BPD with each letter indicating one or more of the 9 symptoms: (Berber MJ. Canadian Family Physician 1997;43:1920)
P : Paranoid ideas (stress-related & transient OR severe dissociative symptoms)
R : Relationship instability (interpersonal relationships are unstable & intense, alternating between extremes of idealization & devaluation)
A: Abandonment fears. Anger outbursts. Affect instability (marked reactivity of mood [e.g. intense episodic dysphoria. irritability or anxiety usually lasting a few hours]
I: Impulsivity (in at least 2 areas that are potentially self-damaging [e.g. spending, sex, substance abuse] and Identity disturbance [unstable self-image or sense of self]
S: Suicidal behavior (gestures or threats or self mutilating behavior))
E: Emptiness (chronic feelings of)
Recommended Reading
Although written more than 20 years ago, the article below summarizes important aspects of Borderline Personality Disorder. The section on medication is now outdated and current pharmacological strategies can be discussed with your personal physician.
“The Dialectical Behavior Skills workbook” by McKay, Wood & Brantley. helps patients to understand and cope with the challenging symptoms of Borderline Personality Disorder.
“Management of Countertransference with Borderline Patients” by Gabbard & Wilkinson is strongly recommended for therapists treating patients with Borderline Personality Disorder.
Attention-Deficit/Hyperactivity Disorder (ADHD)
ADHD is a neurodevelopmental disorder characterized by a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development.
Symptoms must persist for at least 6 months with negative impact on social and academic/occupational activities.
6 or more of 9 inattentive symptoms and/or 6 or more of 9 hyperactive-impulsive symptoms must be present in order to make a diagnosis of ADHD.
For more information go to the ADHD tab on this website.
Schizophrenia
To make a diagnosis of schizophrenia the following features must exist:
A: 2 of 5 symptoms are present during a 1-month period: 1) Delusions, 2) Hallucinations, 3)Disorganized speech, 4) Disorganized behaviour, 5) Negative symptoms
B: Functioning is markedly below level achieved prior to onset of illness
C: Continuous disturbance for at least 6 months
D: Mood disorders with psychotic features are ruled out
E: Symptoms are not due to substance abuse or another medical condition
“A delusion is a false unshakeable belief, which is out of keeping with the patient’s social and cultural background” (Fisch’s Clinical Psychopathology)