Kaplan & Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 10th Edition

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The Patient-Doctor Relationship Kaplan & Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry !"th #dition
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)n effective relationship is characteri%ed +y ,ood rapportRapport is the spontaneo.s conscio.s feelin, of har/onio.s responsiveness that pro/otes the develop/ent of a constr.ctive therape.tic alliance$t i/plies an .nderstandin, and tr.st +et0een the doctor and the patient- 1re2.ently the doctor is the only person to 0ho/ the patients can talk a+o.t thin,s that they cannot tell anyone else- 3ost patients tr.st their doctors to keep secrets and this confidence /.st not +e +etrayedPatients 0ho feel that so/eone kno0s the/ .nderstands the/ and accepts the/ find that a so.rce of stren,th- $n his essay Carin, for the

R)PP*RT

( STR)T#:$#S R)PP*RT

#kkehard *th/er and Sie,linde *th/er defined the develop/ent of rapport as enco/passin, si; strate,ies: 4!9 p.ttin, patients and intervie0ers at ease< 479 findin, patients' pain and e;pressin, co/passion< 4'9 eval.atin, patients' insi,ht and +eco/in, an ally< 4&9 sho0in, e;pertise< 4=9 esta+lishin, a.thority as physicians and therapists< and 4(9 +alancin, the roles of e/pathic listener e;pert and a.thority- )s part of a strate,y for increasin, rapport they developed a checklist 4Ta+le !-!9 that ena+les intervie0ers to reco,ni%e pro+le/s and refine their skills in esta+lishin, rapport-

#/pathy #/pathy is a 0ay of increasin, rapport- $t is an essential characteristic of psychiatrists +.t it is not a .niversal h./an capacity- )n incapacity for nor/al .nderstandin, of 0hat other people are feelin, appears to +e central to certain personality dist.r+ances s.ch as antisocial and narcissistic personality disorders- )ltho.,h e/pathy pro+a+ly cannot +e created it can +e foc.sed and deepened thro.,h trainin, o+servation and self-reflection- $t /anifests in clinical 0ork in a variety of 0ays- )n e/pathic psychiatrist /ay anticipate 0hat is felt +efore it is spoken and can often help patients artic.late 0hat they are feelin,- >onver+al c.es s.ch as +ody post.re and facial e;pression are notedPatients' reactions to the psychiatrist can +e .nderstood and clarified-

"ransference Transference is ,enerally defined as the set of e;pectations +eliefs and e/otional responses that a patient +rin,s to the patient doctor relationship They are +ased not necessarily on 0ho the doctor is or ho0 the doctor acts in reality +.t rather on repeated e;periences the patient has had 0ith other i/portant a.thority fi,.res thro.,ho.t life"ransferential 'ttit(des The patient's attit.de to0ard the physician is apt to +e a repetition of the attit.de he or she has had to0ard a.thority fi,.res- The patient's attit.de can ran,e fro/ one of realistic +asic tr.st 0ith an e;pectation that the doctor has P-7 the patient's +est interest at heart thro.,h one of overideali%ation and even erotici%ed fantasy to one of +asic /istr.st 0ith an e;pectation that the doctor 0ill +e conte/pt.o.s and potentially a+.sive-

Co.ntertransference ?.st as the patient +rin,s transferential attit.des to the patient-doctor relationship doctors the/selves often have co.ntertransferential reactions to their patients- Co.ntertransference can take the for/ of ne,ative feelin,s that are disr.ptive to the patient-doctor relationship +.t it can also enco/pass disproportionately positive ideali%in, or even erotici%ed reactions to patients- ?.st as patients have e;pectations for physicians for e;a/ple co/petence lack of e;ploitation

3odels of $nteraction Bet0een Doctor and Patient

"he paternalistic )odel- $n a paternalistic relationship +et0een the doctor and patient it is ass./ed that the doctor kno0s +est- @e or she 0ill prescri+e treat/ent and the patient is e;pected to co/ply 0itho.t 2.estionin,- 3oreover the doctor /ay decide to 0ithhold infor/ation 0hen it is +elieved to +e in the patient's +est interests$n this /odel also called the a.tocratic /odel the physician asks /ost of the 2.estions and ,enerally do/inates the intervie0-

"he infor)ative )odel* The doctor in this /odel dispenses infor/ation- )ll availa+le data are freely ,iven +.t the choice is left 0holly .p to the patient- 1or e;a/ple doctors /ay 2.ote =-year s.rvival statistics for vario.s treat/ents of +reast cancer and e;pect 0o/en to /ake .p their o0n /inds 0itho.t s.,,estion or interference fro/ the/- This /odel /ay +e appropriate for certain one-ti/e cons.ltations 0here no esta+lished relationship e;ists and the patient 0ill +e ret.rnin, to the re,.lar care of a kno0n physician- )t other ti/es the infor/ative /odel places the patient in an .nrealistically a.tono/o.s role and leaves hi/ or her feelin, the doctor is cold and .ncarin,-

"he interpretive )odel- Doctors 0ho have co/e to kno0 their patients +etter and .nderstand so/ethin, of the circ./stances of their lives their fa/ilies their val.es and their hopes and aspirations are +etter a+le to /ake reco//endations that take into acco.nt the .ni2.e characteristics of an individ.al patient) sense of shared decision-/akin, is esta+lished as the doctor presents and disc.sses alternatives 0ith the patient's participation to find the one that is +est for that partic.lar person- The doctor in this /odel does not a+ro,ate the responsi+ility for /akin, decisions +.t is fle;i+le and is 0illin, to consider 2.estion and alternative s.,,estions-

 "he

deli+erative )odel- The physician in this /odel acts as a friend or co.nselor to the patient not A.st +y presentin, infor/ation +.t in actively advocatin, a partic.lar co.rse of action- The deli+erative approach is co//only .sed +y doctors hopin, to /odify inA.rio.s +ehavior for e;a/ple in tryin, to ,et their patients to stop s/okin, or lose 0ei,ht-

"a+le 1,- 'ssess)ent of !ndivid(al !llness Behavior Prior illness episodes especially illnesses of standard severity 4child+irth renal stones s.r,ery9 C.lt.ral de,ree of stoicis/ C.lt.ral +eliefs concernin, the specific pro+le/ Personal /eanin, of or +eliefs a+o.t the specific pro+le/ Partic.lar 2.estions to ask to elicit the patient's e;planatory /odel: Bhat do yo. call yo.r pro+le/C Bhat na/e does it haveC Bhat do yo. think ca.sed yo.r pro+le/C Bhy do yo. think it started 0hen it didC Bhat does yo.r sickness do to yo.C Bhat do yo. fear /ost a+o.t yo.r sicknessC Bhat are the chief pro+le/s that yo.r sickness has ca.sed yo.C Bhat are the /ost i/portant res.lts yo. hope to

1* .(nctions Deter/inin, the nat.re of the pro+le/ /+0ectives To ena+le the clinician to esta+lish a dia,nosis or reco//end f.rther dia,nostic proced.res s.,,est a co.rse of treat/ent and predict the nat.re of the illness SK!11S Kno0led,e +ase of diseases disorders pro+le/s and clinical hypotheses fro/ /.ltiple concept.al do/ains: +io/edical socioc.lt.ral psychodyna/ic and +ehavioral )+ility to elicit data for the a+ove concept.al do/ains 4enco.ra,in, the patient to tell his or her story: or,ani%in, the flo0 of the intervie0 the for/ of 2.estions the characteri%ation of sy/pto/s the /ental stat.s e;a/ination9 )+ility to perceive data fro/ /.ltiple so.rces 4history /ental stat.s e;a/ination physician's s.+Aective response to the patient nonver+al c.es listenin, at /.ltiple levels9 @ypothesis ,eneration and testin,

7- .(nctions

Developin, and /aintainin, a therape.tic relationship

/+0ectives The patient's 0illin,ness to provide dia,nostic infor/ation Relief of physical and psycholo,ical distress Billin,ness to accept a treat/ent plan or a process of ne,otiation Patient satisfaction Physician satisfaction SK!11S Definin, the nat.re of the relationship )llo0in, the patient to tell his or her story @earin, +earin, and toleratin, the patient's e;pression of painf.l feelin,s )ppropriate and ,en.ine interest e/pathy s.pport and co,nitive .nderstandin, )ttendin, to co//on patient concerns over e/+arrass/ent sha/e and h./iliation #licitin, the patient's perspective Deter/inin, the nat.re of the pro+le/ Co//.nicatin, infor/ation and reco//endin, treat/ent 4f.nction

'-1E>:T$*>S Co//.nicatin, infor/ation and i/ple/entin, a treat/ent plan /B2EC"!3E Patient's (nderstandin4 of the illness Patient's (nderstandin4 of the s(44ested dia4nostic proced(res Patient's (nderstandin4 of the treat)ent possi+ilities Consens(s +et5een physician and patient a+o(t the a+ove ite)s 1 to % !nfor)ed consent !)prove copin4 )echanis)s 1ifestyle chan4es SK!11S eter)inin4 the nat(re of the pro+le) 6f(nction !7 evelopin4 a therape(tic relationship 6f(nction !!7 Esta+lishin4 the differences in perspective +et5een physician and patient

Predicta+le Reactions to $llness Clinical $ntrapsychic

Do0ered self i/a,e loss Threat to ho/eostasis fear 1ail.re of 4self9 care helplessness hopelessness Sense of loss of control sha/e 4,.ilt9

)n;iety or depression Denial or an;iety Depression Bar,ainin, and +la/in, Re,ression $solation Dependency )n,er )cceptance

Co))on !ntervie5 "echni8(es #sta+lish rapport as early in the intervie0 as possi+leDeter/ine the patient's chief co/plaintEse the chief co/plaint to develop a provisional differential dia,nosisR.le the vario.s dia,nostic possi+ilities o.t or in +y .sin, foc.sed and detailed 2.estions1ollo0 .p on va,.e or o+sc.re replies 0ith eno.,h persistence to acc.rately deter/ine the ans0er to the 2.estionDet the patient talk freely eno.,h to o+serve ho0 ti,htly the tho.,hts are connectedEse a /i;t.re of open-ended and closed-ended 2.estionsDon't +e afraid to ask a+o.t topics that yo. or the patient /ay find diffic.lt or e/+arrassin,)sk a+o.t s.icidal tho.,hts:ive the patient a chance to ask 2.estions at the end of the intervie0Concl.de the initial intervie0 +y conveyin, a sense of confidence and if possi+le of hopeReprinted 0ith per/ission fro/ )ndreasen >C Black DB$ntrod.ction Te;t+ook of Psychiatry- Bashin,ton DC: )/erican Psychiatric )ssociation !66!-

Character and F.alities of the Physician

$/pert.r+a+ility The a+ility to /aintain e;tre/e cal/ and steadiness Presence of /ind Selfcontrol in an e/er,ency or e/+arrassin, sit.ation so that one can say or do the ri,ht thin, Clear A.d,/ent The a+ility to /ake an

)+ility to end.re fr.stration The capacity to re/ain fir/ and deal 0ith insec.rity and dissatisfaction $nfinite patienceThe .nli/ited a+ility to hear pain or trial cal/ly Charity to0ard othersTo +e ,enero.s and helpf.l especially to0ard the needy and s.fferin,

Character and F.alities of the Physician

The search for a+sol.te tr.th To investi,ate facts and p.rs.e reality Co/pos.re Cal/ness of /ind +earin, and appearance Bravery The capacity to face or end.re events 0ith co.ra,e Tenacity To +e persistent in attainin, a ,oal or adherin, to so/ethin, val.ed

$dealis/ 1or/in, standards and ideals and livin, .nder their infl.ence #2.ani/ity The a+ility to handle stressf.l sit.ations 0ith an .ndist.r+ed even te/per

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 Deliri./ Deliri./

is /arked +y short-ter/ conf.sion and chan,es in co,nitionThere are fo.r s.+cate,ories +ased on several ca.ses: 4!9 ,eneral /edical condition 4e-,- infection9< 479 s.+stance ind.ced 4e-,- cocaine opioids phencyclidine HPCPI9< 4'9 /.ltiple ca.ses 4e-,- head tra./a and kidney disease9< and 4&9 deliri./ not other0ise specified 4e-,- sleep deprivation9-

De/entia De/entia is /arked +y severe i/pair/ent in /e/ory A.d,/ent orientation and co,nition- The si; s.+cate,ories are 4!9 de/entia of the )l%hei/er's type 0hich .s.ally occ.rs in persons over (= years of a,e and is /anifested +y pro,ressive intellect.al disorientation and de/entia del.sions or depression< 479 vasc.lar de/entia ca.sed +y vessel thro/+osis or he/orrha,e< 4'9 other /edical conditions 4e-,- h./an i//.nodeficiency vir.s H@$JI disease head tra./a Pick's disease Cre.t%feldt-?ako+ disease 0hich is ca.sed +y a slo0-,ro0in, trans/itta+le vir.s9< 4&9 s.+stance ind.ced ca.sed +y to;in or /edication 4e-,- ,asoline f./es atropine9< 4=9 /.ltiple etiolo,ies< and 4(9

 )/nestic

Disorder )/nestic disorder is /arked +y /e/ory i/pair/ent and for,etf.lness The three s.+cate,ories are 4!9 ca.sed +y /edical condition 4hypo;ia9< 479 ca.sed +y to;in or /edication 4e-,- /ariA.ana dia%epa/9< and 4'9 not other0ise specified-

S9,!3,": Co4nitive isorders Deliri./ KKKCa.sed +y a ,eneral /edical condition KKKS.+stance-ind.ced KKK1ro/ /.ltiple etiolo,ies KKK>ot other0ise specified De/entia KKK*f the )l%hei/er's type KKKJasc.lar KKKDe/entia d.e to other ,eneral /edical conditions KKKKKK@./an i//.nodeficiency vir.s 4@$J9 disease KKKKKK@ead tra./a KKKKKKParkinson's disease KKKKKK@.ntin,ton's disease KKKKKKPick's disease KKKKKKCre.t%feldt-?ako+ disease KKKKKK*ther ,eneral /edical conditions KKKS.+stance-ind.ced persistin, de/entia KKK3.ltiple etiolo,ies KKKDe/entia not other0ise specified )/nestic Disorders KKKCa.sed +y a ,eneral /edical condition KKKS.+stance-ind.ced persistin, a/nestic disorder KKK>ot other0ise specified Co,nitive disorder not other0ise specified

;e(ropsychiatric 9ental Stat(s E<a)ination

1*=eneral escription L =eneral appearance, dress, sensory aids 64lasses, hearin4 aid7 L 1evel of conscio(sness and aro(sal L 'ttention to environ)ent L Post(re 6standin4 and seated7 L =ait L 9ove)ents of li)+s, tr(nk, and face 6spontaneo(s, restin4, and after instr(ction7 L =eneral de)eanor 6incl(din4 evidence of responses to internal sti)(li7 L :esponse to e<a)iner 6eye contact, cooperation, a+ility to foc(s on intervie5 process7 L ;ative or pri)ary lan4(a4e -,1an4(a4e and Speech L Co)prehension 65ords, sentences, si)ple and co)ple< co))ands, and concepts7 L /(tp(t 6spontaneity, rate, fl(ency, )elody or prosody, vol()e, coherence, voca+(lary, paraphasic errors, co)ple<ity of (sa4e7 L :epetition L /ther aspects /+0ect na)in4 Color na)in4

'-Tho.,ht 1or/ 4coherence and connectedness9 Content

L $deational 4preocc.pations overval.ed ideas del.sions9 L Percept.al 4hall.cinations9

&-3ood and )ffect $nternal /ood state 4spontaneo.s and elicited< sense of h./or9 1.t.re o.tlook S.icidal ideas and plans De/onstrated e/otional stat.s 4con,r.ence 0ith /ood9 =-$nsi,ht and ?.d,/ent $nsi,ht
L Self-appraisal and self-estee/ L Enderstandin, of c.rrent circ./stances L )+ility to descri+e personal psycholo,ical and physical stat.s

?.d,/ent

(- Co,nition 3e/ory

L Spontaneo.s 4as evidenced d.rin, intervie09 L Tested 4incidental i//ediate repetition delayed recall c.ed recall reco,nition< ver+al nonver+al< e;plicit i/plicit9

Jis.ospatial skills Constr.ctional a+ility 3athe/atics Readin, Britin, 1ine sensory f.nction 4stereo,nosis ,raphesthesia t0o-point discri/ination9 1in,er ,nosis Ri,ht-left orientation #;ec.tive f.nctions )+straction

Central nervo.s syste/ disordeRM Sei%.re 4postictal nonconv.lsive stat.s stat.s9 3i,raine @ead tra./a +rain t./or s.+arachnoid he/orrha,e s.+d.ral epid.ral he/ato/a a+scess intracere+ral he/orrha,e cere+ellar he/orrha,e nonhe/orrha,ic stroke transient ische/ia 3eta+olic disorder M#lectrolyte a+nor/alities Dia+etes hypo,lyce/ia hyper,lyce/ia or ins.lin resistance Syste/ic illness $nfectionM 4e-,- sepsis /alaria erysipelas viral pla,.e Dy/e disease syphilis or a+scess9 Tra./a Chan,e in fl.id stat.s 4dehydration or vol./e overload9 >.tritional deficiency B.rns Encontrolled pain

Co//on Ca.ses of Deliri./

3edications M Pain /edications 4e-,postoperative /eperidine HDe/erolI or /orphine HD.ra/orphI9 )nti+iotics antivirals and antif.n,als Steroids )nesthesia Cardiac /edications )ntihypertensives )ntineoplastic a,ents )nticholiner,ic a,ents >e.roleptic /ali,nant syndro/e Serotonin syndro/e *ver-the-co.nter preparationsM @er+als teas and n.tritional s.pple/ents Botanicals? i/son0eed oleander fo;,love he/lock dieffen+achia and Amanita phalloides Cardiac MCardiac fail.re arrhyth/ia /yocardial infarction cardiac assist device

P.l/onary Chronic o+str.ctive p.l/onary disease hypo;ia S$)D@ acid +ase dist.r+ance #ndocrine )drenal crisis or adrenal fail.re thyroid a+nor/ality parathyroid a+nor/ality @e/atolo,ical )ne/ia le.ke/ia +lood dyscrasia ste/ cell transplant Renal Renal fail.re .re/ia S$)D@ @epatic @epatitis cirrhosis hepatic fail.re >eoplas/>eoplas/ 4pri/ary +rain /etastases paraneoplastic syndro/e9 Dr.,s of a+.se $nto;ication and 0ithdra0al To;ins$n to;ication and 0ithdra0al @eavy /etals and al./in./

S9,!3,": ia4nostic Criteria for eliri() (e to =eneral 9edical Condition Dist.r+ance of conscio.sness 4i-e- red.ced clarity of a0areness of the environ/ent9 0ith red.ced a+ility to foc.s s.stain or shift attention ) chan,e in co,nition 4s.ch as /e/ory deficit disorientation lan,.a,e dist.r+ance9 or the develop/ent of a percept.al dist.r+ance that is not +etter acco.nted for +y a pree;istin, esta+lished or evolvin, de/entia The dist.r+ance develops over a short period of ti/e 4.s.ally ho.rs to days9 and tends to fl.ct.ate d.rin, the co.rse of the day There is evidence fro/ the history physical e;a/ination or la+oratory findin,s that the dist.r+ance is ca.sed +y the direct physiolo,ical conse2.ences of a ,eneral /edical condition Codin, note: $f deliri./ is s.peri/posed on a pree;istin, vasc.lar de/entia indicate the deliri./ +y codin, vasc.lar de/entia 0ith deliri./Codin, note: $ncl.de the na/e of the ,eneral /edical

Physical #;a/ination of the Delirio.s Patient

P.lse Bradycardia M @ypothyroidis/ Stokes-)da/s syndro/e $ncreased intracranial press.reK TachycardiaM @yperthyroidis/ $nfection @eart fail.re Te/perat.reM 1ever Sepsis Thyroid stor/ Jasc.litis Blood press.re -@ypotension Shock @ypothyroidis/ )ddison's disease

 Respiration

LNTachypnea Dia+etes Pne./onia Cardiac fail.re 1ever )cidosis 4/eta+olic9 -KShallo0 )lcohol or other s.+stance into;ication Carotid vessels Br.its or decreased p.lse --Transient cere+ral ische/ia Scalp and face #vidence of tra./aK

 >eck

#vidence of n.chal ri,idity 3enin,itis S.+arachnoid he/orrha,e #yes -Papill ede/aT./or @ypertensive encephalopathyK -P.pillary dilatation)n;iety ).tono/ic overactivity 4e-,deliri./ tre/ens9 3o.th Ton,.e or cheeK lacerations #vidence of ,enerali%ed tonic-clonic sei%.res

 @eart

)rrhyth/ia $nade2.ate cardiac o.tp.t possi+ility of e/+oliK Cardio/e,aly @eart fail.re @ypertensive disease D.n,s Con,estion Pri/ary p.l/onary fail.re P.l/onary ede/a Pne./onia Breath )lcoholKK Ketones Dia+etes Diver - #nlar,e/ent Cirrhosis

>ervo.s syste/
Ka- Refle;es /.scle stretch )sy//etry 0ith Ba+inski's si,ns 3ass lesion Cere+rovasc.lar disease Pree;istin, de/entiaK Sno.t 1rontal /ass Bilateral posterior cere+ral artery occl.sion +- )+d.cent nerve 4si;th cranial nerve9 Beakness in lateral ,a%e $ncreased intracranial press.reKK c- Di/+ stren,th )sy//etrical 3ass lesion Cere+rovasc.lar diseaseKKK

De/entia

De/entia is defined as a pro,ressive i/pair/ent of co,nitive f.nctions occ.rrin, in clear conscio.sness 4i-e- in the a+sence of deliri./9De/entia consists of a variety of sy/pto/s that s.,,est chronic and 0idespread dysf.nction- :lo+al i/pair/ent of intellect is the essential feat.re /anifested as diffic.lty 0ith /e/ory attention thinkin, and co/prehension*ther /ental f.nctions can often +e affected incl.din, /ood personality A.d,/ent and social +ehavior- )ltho.,h specific dia,nostic criteria are fo.nd for vario.s de/entias s.ch as )l%hei/er's disease or vasc.lar de/entia all de/entias have certain co//on ele/ents that res.lt in si,nificant i/pair/ent in social or occ.pational f.nctionin, and ca.se a si,nificant decline fro/ a previo.s level of

Possi+le Etiolo4ies of e)entia e4enerative de)entias KKK)l%hei/er's disease KKK1rontote/poral de/entias 4e-,- Pick's disease9 KKKParkinson's disease KKKDe0y +ody de/entia KKK$diopathic cere+ral ferrocalcinosis 41ahr's disease9 KKKPro,ressive s.pran.clear palsy 9iscellaneo(s KKK@.ntin,ton's disease KKKBilson's disease KKK3etachro/atic le.kodystrophy KKK>e.roacanthocytosis Psychiatric KKKPse.dode/entia of depression KKKCo,nitive decline in late-life schi%ophrenia Physiolo4ic KKK>or/al press.re hydrocephal.s 9eta+olic KKKJita/in deficiencies 4e-,- vita/in B!7 folate9 KKK#ndocrinopathies 4e-,- hypothyroidis/9 KKKChronic /eta+olic dist.r+ances 4e-,- .re/ia9

"()or KKKPri/ary or /etastatic 4e-,- /enin,io/a or /etastatic +reast or l.n, cancer9 "ra()atic KKKDe/entia p.,ilistica posttra./atic de/entia KKKS.+d.ral he/ato/a !nfection KKKPrion diseases 4e-,- Cre.t%feldt-?ako+ disease +ovine spon,ifor/ encephalitis :erst/annStrOP.ssler syndro/e9 KKK)c2.ired i//.ne deficiency syndro/e 4)$DS9 KKKSyphilis Cardiac, vasc(lar, and ano<ia KKK$nfarction 4sin,le or /.ltiple or strate,ic lac.nar9 KKKBins0an,er's disease 4s.+cortical arteriosclerotic encephalopathy9 KKK@e/odyna/ic ins.fficiency 4e-,- hypoperf.sion or hypo;ia9 e)yelinatin4 diseases KKK3.ltiple sclerosis r(4s and to<ins KKK)lcohoD @eavy /etals KKK$rradiation

Differential Dia,nosis

De/entia of the )l%hei/er's Type vers.s Jasc.lar De/entia Classically vasc.lar de/entia has +een distin,.ished fro/ de/entia of the )l%hei/er's type +y the decre/ental deterioration that can acco/pany cere+rovasc.lar disease over ti/e)ltho.,h the discrete step0ise deterioration /ay not +e apparent in all cases focal ne.rolo,ical sy/pto/s are /ore co//on in vasc.lar de/entia than in de/entia of the )l%hei/er's type as are the standard risk factors for

Jasc.lar De/entia vers.s Transient $sche/ic )ttacks Transient ische/ic attacks 4T$)s9 are +rief episodes of focal ne.rolo,ical dysf.nction lastin, less than 7& ho.rs 4.s.ally = to != /in.tes9- )ltho.,h a variety of /echanis/s /ay +e responsi+le the episodes are fre2.ently the res.lt of /icroe/+oli%ation fro/ a pro;i/al intracranial arterial lesion that prod.ces transient +rain ische/ia and the episodes .s.ally resolve 0itho.t si,nificant patholo,ical alteration of the parenchy/al tiss.e- )ppro;i/ately one third of persons 0ith .ntreated T$)s e;perience a +rain infarction later< therefore reco,nition of T$)s is an i/portant clinical strate,y to prevent +rain infarctionClinicians sho.ld distin,.ish episodes involvin, the verte+ro+asilar syste/ fro/ those involvin, the carotid arterial syste/- $n ,eneral sy/pto/s of verte+ro+asilar disease reflect a transient f.nctional dist.r+ance in either the +rainste/ or the occipital lo+e< carotid distri+.tion sy/pto/s reflect .nilateral retinal or he/ispheric a+nor/ality- )nticoa,.lant therapy

Deliri./ Differentiatin, +et0een deliri./ and de/entia can +e /ore diffic.lt than the DS3-$J-TR classification indicates- $n ,eneral deliri./ is distin,.ished +y rapid onset +rief d.ration co,nitive i/pair/ent fl.ct.ation d.rin, the co.rse of the day noct.rnal e;acer+ation of sy/pto/s /arked dist.r+ance of the sleepQRS0ake cycle and pro/inent dist.r+ances in attention and perceptionDepression So/e patients 0ith depression have sy/pto/s of co,nitive i/pair/ent diffic.lt to distin,.ish fro/ sy/pto/s of de/entia- The clinical pict.re is so/eti/es referred to as pse.dode/entia altho.,h the ter/ depression-related co,nitive dysf.nction is prefera+le and /ore descriptive 4Ta+le !"-'-!!9- Patients 0ith depression-related co,nitive dysf.nction ,enerally have pro/inent depressive sy/pto/s /ore insi,ht into their sy/pto/s than do de/ented patients and often

1actitio.s Disorder Persons 0ho atte/pt to si/.late /e/ory loss as in factitio.s disorder do so in an erratic and inconsistent /anner- $n tr.e de/entia /e/ory for ti/e and place is lost +efore /e/ory for person and recent /e/ory is lost +efore re/ote /e/orySchi%ophrenia )ltho.,h schi%ophrenia can +e associated 0ith so/e ac2.ired intellect.al i/pair/ent its sy/pto/s are /.ch less severe than are the related sy/pto/s of psychosis and tho.,ht disorder seen in de/entia>or/al ),in, ),in, is not necessarily associated 0ith any si,nificant co,nitive decline +.t /inor /e/ory pro+le/s can occ.r as a nor/al part of a,in,- These nor/al occ.rrences are so/eti/es referred to as +eni,n senescent for,etf.lness or a,e-associated /e/ory i/pair/ent- They are distin,.ished fro/ de/entia +y their /inor severity and +eca.se they do not interfere

!C ,10

ia4nostic Criteria fo:

e)entia

:!- "here is evidence of each of the follo5in4: ' decline in )e)ory, 5hich is )ost evident in the learnin4 of ne5 infor)ation, altho(4h, in )ore severe cases, the recall of previo(sly learned infor)ation )ay also +e affected* "he i)pair)ent applies to +oth ver+al and nonver+al )aterial* "he decline sho(ld +e o+0ectively verified +y o+tainin4 a relia+le history fro) an infor)ant, s(pple)ented, if possi+le, +y ne(ropsycholo4ical tests or 8(antified co4nitive assess)ents* "he severity of the decline, 5ith )ild i)pair)ent as the threshold for dia4nosis, sho(ld +e assessed as follo5s:

Mild. "he de4ree of )e)ory loss is s(fficient to interfere 5ith everyday activities, tho(4h not so severe as to +e inco)pati+le 5ith independent livin4* "he )ain f(nction affected is the learin4 of ne5 )aterial* .or e<a)ple, the individ(al has diffic(lty in re4isterin4, storin4, and recallin4 ele)ents involved in daily livin4 s(ch as 5here +elon4in4s have +een p(t, social arran4e)ents, or infor)ation recently i)parted +y fa)ily )e)+ers*

Moderate. "he de4ree of )e)ory loss represents a serio(s handicap to independent livin4* /nly hi4hly learned or very fa)iliar )aterial is retained* ;e5 infor)ation is retained only occasionally and very +riefly* !ndivid(als are (na+le to recall +asic infor)ation a+o(t their o5n local 4eo4raphy, 5hat they have recently +een doin4, or the na)es of fa)iliar people*

) decline in other co,nitive a+ilities characteri%ed +y deterioration in A.d,/ent and thinkin, s.ch as plannin, and or,ani%in, and in the ,eneral processin, of infor/ation- #vidence for this sho.ld ideally +e o+tained fro/ an infor/ant and s.pple/ented if possi+le +y ne.ropsycholo,ical tests or 2.antified o+Aective assess/ents- Deterioration fro/ a previo.sly hi,her level of perfor/ance sho.ld +e esta+lished- The severity of the decline 0ith /ild i/pair/ent as the threshold for dia,nosis sho.ld +e assessed as follo0s: Mild. The decline in co,nitive a+ilities ca.ses i/paired perfor/ance in daily livin, +.t not to a de,ree that /akes the individ.al dependent on others- Co/plicated daily tasks or recreational activities cannot +e .ndertakenModerate. The decline in co,nitive a+ilities /akes the individ.al .na+le to f.nction 0itho.t the assistance of another in daily livin, incl.din, shoppin, and handlin, /oney- Bithin the ho/e only si/ple chores can +e perfor/ed- )ctivities are increasin,ly restricted and

:7- )0areness of the environ/ent 4i-e- a+sence of clo.din, of conscio.sness Has defined in deliri./ not ind.ced +y alcohol and other psychoactive s.+stances- Criterion )I9 is preserved d.rin, a period s.fficiently lon, to allo0 the .ne2.ivocal de/onstration of the sy/pto/s in Criterion - Bhen there are s.peri/posed episodes of deliri./ the dia,nosis of de/entia sho.ld +e deferred :'- There is a decline in e/otional control or /otivation or a chan,e in social +ehavior /anifest as at least one of the follo0in,: e/otional la+ility irrita+ility apathy coarsenin, of social +ehavior :&- 1or a confident clinical dia,nosis the sy/pto/s in criterion :! sho.ld have +een present for at least ( /onths< if the period since

The a/nestic disorders

The a/nestic disorders are a +road cate,ory that incl.des a variety of diseases and conditions that present 0ith an a/nestic syndro/e- The syndro/e is defined pri/arily +y i/pair/ent in the a+ility to create ne0 /e/ories- Three variations of the a/nestic disorder dia,nosis differin, in etiolo,y are offered: a/nestic disorder ca.sed +y a ,eneral /edical condition 4e-,- head tra./a9 s.+stance-ind.ced persistin, a/nestic disorder 4e-,- ca.sed +y car+on /ono;ide poisonin, or chronic alcohol cons./ption9 and a/nestic disorder not other0ise specified for cases in 0hich the etiolo,y is .nclear- The t0o /odifiers are 4!9 transient for d.ration less than ! /onth and 479 chronic for conditions e;tendin, +eyond ! /onth-

9a0or Ca(ses of ')nestic isorders

Syste/ic /edical conditions KKKThia/ine deficiency 4Korsakoff's syndro/e9 @ypo,lyce/ia Pri/ary +rain conditions KKKSei%.res KKK@ead tra./a 4closed and penetratin,9 KKKCere+ral t./ors 4especially thala/ic and te/poral lo+e9 KKKCere+rovasc.lar diseases 4especially thala/ic and te/poral lo+e9 KKKS.r,ical proced.res on the +rain KKK#ncephalitis d.e to herpes si/ple; KKK@ypo;ia 4incl.din, nonfatal han,in, atte/pts and car+on /ono;ide poisonin,9 KKKTransient ,lo+al a/nesia KKK#lectroconv.lsive therapy KKK3.ltiple sclerosis S.+stance-related ca.ses KKK)lcohol .se disorders KKK>e.roto;ins KKKBen%odia%epines 4and other sedative-hypnotics9 KKK3any over-the-co.nter preparations

S9,!3,": ia4nostic Criteria for ')nestic isorder (e to a =eneral 9edical Condition The develop/ent of /e/ory i/pair/ent as /anifested +y i/pair/ent in the a+ility to learn ne0 infor/ation or the ina+ility to recall previo.sly learned infor/ationThe /e/ory dist.r+ance ca.ses si,nificant i/pair/ent in social or occ.pational f.nctionin, and represents a si,nificant decline fro/ a previo.s level of f.nctionin,The /e/ory dist.r+ance does not occ.r e;cl.sively d.rin, the co.rse of a deliri./ or a de/entiaThere is evidence fro/ the history physical e;a/ination or la+oratory findin,s that the dist.r+ance is the direct physiolo,ical conse2.ence of a ,eneral /edical condition 4incl.din, physical tra./a9Specify if: KKK"ransient: if /e/ory i/pair/ent lasts for ! /onth or less KKKChronic: if /e/ory i/pair/ent lasts for /ore

Depression and Bipolar Disorder

3ood is a pervasive and s.stained feelin, tone that is e;perienced internally and that infl.ences a person's +ehavior and perception of the 0orld )ffect is the e;ternal e;pression of /ood3ood can +e: nor/al elevated or depressed @ealthy persons e;perience a 0ide ran,e of /oods and have an e2.ally lar,e repertoire of affective e;pressions< they feel in control of their /oods and affects

3ood disorders are a ,ro.p of clinical conditions characteri%ed +y a loss of that sense of control and a s.+Aective e;perience of ,reat distressPatients 0ith elevated /ood de/onstrate e;pansiveness fli,ht of ideas decreased sleep and ,randiose ideasPatients 0ith depressed /ood e;perience a loss of ener,y and interest feelin,s of ,.ilt diffic.lty in concentratin, loss of appetite and tho.,hts of death or s.icide*ther si,ns and sy/pto/s of /ood disorders incl.de chan,e in activity level co,nitive a+ilities speech and ve,etative f.nctions 4e-,- sleep appetite se;.al activity and other +iolo,ical rhyth/s9These disorders virt.ally al0ays res.lt in i/paired interpersonal social and

 Patients

afflicted 0ith only /aAor depressive episodes are said to have /aAor depressive disorder or .nipolar depression Patients 0ith +oth /anic and depressive episodes or patients 0ith /anic episodes alone are said to have +ipolar disorder The ter/s .nipolar /ania and p.re /ania are so/eti/es .sed for patients 0ho are +ipolar +.t 0ho do not have depressive episodes-

Three additional cate,ories of /ood disorders are: @ypo/ania cyclothy/ia dysthy/ia @ypo/ania is an episode of /anic sy/pto/s that does not /eet the f.ll te;t revision of the fo.rth edition of Dia,nostic and Statistical 3an.al of 3ental Disorders 4DS3-$J-TR9 criteria for /anic episode Cyclothy/ia and dysthy/ia are defined +y DS3-$J-TR as disorders that represent less severe for/s of +ipolar disorder and /aAor depression respectively-

!ncidence and Prevalence 3ood disorders are co//on- $n the /ost recent s.rveys /aAor depressive disorder has the hi,hest lifeti/e prevalence 4al/ost !8 percent9 of any psychiatric disorder The lifeti/e prevalence rate of different for/s of DS3$J-TR .nipolar depressive disorder accordin, to the ei,ht /aAor co//.nity s.rveys are sho0n in Ta+le !=-!-!- The yearly incidence of a /aAor depression is !-=6 percent 40o/en !-56 percent< /en !-!" percent9 The lifeti/e prevalence rates of different clinical for/s of +ipolar disorder are sho0n in Ta+le !=-!-7 The ann.al incidence 4n./+er of ne0 cases9 of a /aAor depressive episode is !-=6 percent 40o/en !-56 percent< /en !-!" percent9 The ann.al incidence of +ipolar illness is less than ! percent +.t it is diffic.lt to esti/ate +eca.se /ilder

S9,!3,": Criteria for 9a0or epressive Episode 1ive 4or /ore9 of the follo0in, sy/pto/s have +een present d.rin, the sa/e 7-0eek period and represent a chan,e fro/ previo.s f.nctionin,< at least one of the sy/pto/s is either 4!9 depressed /ood or 479 loss of interest or pleas.re;ote: Do not incl.de sy/pto/s that are clearly d.e to a ,eneral /edical condition or /ood-incon,r.ent del.sions or hall.cinationsL depressed /ood /ost of the day nearly every day as indicated +y either s.+Aective report 4e-,- feels sad or e/pty9 or o+servation /ade +y others 4e-,appears tearf.l9- ;ote: $n children and adolescents can +e irrita+le /ood L /arkedly di/inished interest or pleas.re in all or al/ost all activities /ost of the day nearly every day 4as indicated +y either s.+Aective acco.nt or

L si,nificant 0ei,ht loss 0hen not dietin, or 0ei,ht ,ain 4e-,- a chan,e of /ore than =T of +ody 0ei,ht in a /onth9 or decrease or increase in appetite nearly every day- ;ote: $n children consider fail.re to /ake e;pected 0ei,ht ,ainsL inso/nia or hyperso/nia nearly every day L psycho/otor a,itation or retardation nearly every day 4o+serva+le +y others not /erely s.+Aective feelin,s of restlessness or +ein, slo0ed do0n9

L psycho/otor a,itation or retardation nearly every day 4o+serva+le +y others not /erely s.+Aective feelin,s of restlessness or +ein, slo0ed do0n9 L fati,.e or loss of ener,y nearly every day L feelin,s of 0orthlessness or e;cessive or inappropriate ,.ilt 40hich /ay +e del.sional9 nearly every day 4not /erely self-reproach or ,.ilt a+o.t +ein, sick9 L di/inished a+ility to think or concentrate or indecisiveness nearly every day 4either +y s.+Aective acco.nt or as o+served +y others9 L rec.rrent tho.,hts of death 4not A.st fear of dyin,9 rec.rrent s.icidal ideation 0itho.t a specific plan or a s.icide atte/pt or a specific plan for co//ittin, s.icide

The sy/pto/s do not /eet criteria for a /i;ed episodeThe sy/pto/s ca.se clinically si,nificant distress or i/pair/ent in social occ.pational or other i/portant areas of f.nctionin,The sy/pto/s are not d.e to the direct physiolo,ical effects of a s.+stance 4e-,- a dr., of a+.se a /edication9 or a ,eneral /edical condition 4e-,- hypothyroidis/9The sy/pto/s are not +etter acco.nted for +y +ereave/ent i-e- after the loss of a loved one the sy/pto/s persist for lon,er than 7 /onths o are characteri%ed +y /arked f.nctional i/pair/ent /or+id preocc.pation 0ith 0orthlessness s.icidal ideation psychotic sy/pto/s or psycho/otor retardation-

S9,!3,": Criteria for 9anic Episode ) distinct period of a+nor/ally and persistently elevated e;pansive or irrita+le /ood lastin, at least ! 0eek 4or any d.ration if hospitali%ation is necessary9 D.rin, the period of /ood dist.r+ance three 4or /ore9 of the follo0in, sy/pto/s have persisted 4fo.r if the /ood is only irrita+le9 and have +een present to a si,nificant de,ree:

L inflated self-estee/ or ,randiosity L decreased need for sleep 4e-,- feels rested after only ' ho.rs of sleep9 L /ore talkative than .s.al or press.re to keep

L fli,ht of ideas or s.+Aective e;perience that tho.,hts are racin, L distracti+ility 4i-e- attention too easily dra0n to .ni/portant or irrelevant e;ternal sti/.li9 L increase in ,oal-directed activity 4either socially at 0ork or school or se;.ally9 or psycho/otor a,itation L e;cessive involve/ent in pleas.ra+le activities that have a hi,h potential for painf.l conse2.ences 4e-,- en,a,in, in .nrestrained +.yin, sprees se;.al indiscretions or foolish +.siness invest/ents9

The sy/pto/s do not /eet criteria for a /i;ed episodeThe /ood dist.r+ance is s.fficiently severe to ca.se /arked i/pair/ent in occ.pational f.nctionin, or in .s.al social activities or relationships 0ith others or to necessitate hospitali%ation to prevent har/

The sy/pto/s are not d.e to the direct physiolo,ical effects of a s.+stance 4e-,a dr., of a+.se a /edication or other treat/ent9 or a ,eneral /edical condition 4e-,- hyperthyroidis/9;ote: 3anic-like episodes that are clearly ca.sed +y so/atic antidepressant treat/ent 4e-,- /edication electroconv.lsive therapy li,ht therapy9 sho.ld not co.nt to0ard a dia,nosis of +ipolar $ disorder41ro/ )/erican Psychiatric )ssociationDiagnostic and Statistical Manual of Mental Disorders- &th ed- Te;t rev- Bashin,ton DC: )/erican Psychiatric )ssociation

S9,!3,": Criteria for >ypo)anic Episode ) distinct period of persistently elevated e;pansive or irrita+le /ood lastin, thro.,ho.t at least & days that is clearly different fro/ the .s.al nondepressed /ood D.rin, the period of /ood dist.r+ance three 4or /ore9 of the follo0in, sy/pto/s have persisted 4fo.r if the /ood is only irrita+le9 and have +een present to a si,nificant de,ree:

L fli,ht of ideas or s.+Aective e;perience that tho.,hts are racin, L distracti+ility 4i-e- attention too easily dra0n to .ni/portant or irrelevant e;ternal sti/.li9 L increase in ,oal-directed activity 4either socially at 0ork or school or se;.ally9 or psycho/otor a,itation L e;cessive involve/ent in pleas.ra+le activities that have a hi,h potential for painf.l conse2.ences 4e-,- the person en,a,es in .nrestrained +.yin, sprees se;.al indiscretions or foolish +.siness invest/ents9

The episode is associated 0ith an .ne2.ivocal chan,e in f.nctionin, that is .ncharacteristic of the person 0hen not sy/pto/aticThe dist.r+ance in /ood and the chan,e in f.nctionin, are o+serva+le +y othersThe episode is not severe eno.,h to ca.se /arked i/pair/ent in social or occ.pational f.nctionin, or to necessitate hospitali%ation and there are no psychotic feat.resThe sy/pto/s are not d.e to the direct physiolo,ical effects of a s.+stance 4e-,- a dr., of a+.se a /edication or other treat/ent9 or a ,eneral /edical condition 4e-,- hyperthyroidis/9;ote: @ypo/anic-like episodes that are clearly ca.sed +y so/atic antidepressant treat/ent 4e-,- /edication

S9,!3,": Criteria for 9i<ed Episode The criteria are /et +oth for a /anic episode and for a /aAor depressive episode 4e;cept for d.ration9 nearly every day d.rin, at least a !0eek periodThe /ood dist.r+ance is s.fficiently severe to ca.se /arked i/pair/ent in occ.pational f.nctionin, or in .s.al social activities or relationships 0ith others or to necessitate hospitali%ation to prevent har/ to self or others or there are psychotic feat.resThe sy/pto/s are not d.e to the direct physiolo,ical effects of a s.+stance 4e-,- a dr., of a+.se a /edication or other treat/ent9 or a ,eneral /edical condition 4e-,hyperthyroidis/9;ote: 3i;ed-like episodes that are clearly ca.sed +y so/atic antidepressant treat/ent

S9,!3,": Criteria for Severity/Psychotic/ :e)ission Specifiers for C(rrent 6or 9ost :ecent7 9a0or epressive Episode ;ote: Code in fifth di,it- 3ild /oderate severe 0itho.t psychotic feat.res and severe 0ith psychotic feat.res can +e applied only if the criteria are c.rrently /et for a /aAor depressive episode- $n partial re/ission and in f.ll re/ission can +e applied to the /ost recent /aAor depressive episode in /aAor depressive disorder and to a /aAor depressive episode in +ipolar $ or $$ disorder only if it is the /ost recent type of /ood episode9ild: 1e0 if any sy/pto/s in e;cess of those re2.ired to /ake the dia,nosis and sy/pto/s res.lt in only /inor i/pair/ent in occ.pational f.nctionin, or in .s.al social activities or relationships 0ith others9oderate: Sy/pto/s or f.nctional i/pair/ent +et0een /ild and severe-

Severe 5itho(t psychotic feat(res: Several sy/pto/s in e;cess of those re2.ired to /ake the dia,nosis and sy/pto/s /arkedly interfere 0ith occ.pational f.nctionin, or 0ith .s.al social activities or relationships 0ith othersSevere 5ith psychotic feat(res: Del.sions or hall.cinations- $f possi+le specify 0hether the psychotic feat.res are /ood-con,r.ent or /oodincon,r.ent: KKK9ood,con4r(ent psychotic feat(res: Del.sions or hall.cinations 0hose content is entirely consistent 0ith the typical depressive the/es of personal inade2.acy ,.ilt disease death nihilis/ or deserved p.nish/entKKK9ood,incon4r(ent psychotic feat(res: Del.sions or hall.cinations 0hose content does not involve typical depressive the/es of personal inade2.acy ,.ilt disease death nihilis/ or deserved p.nish/ent- $ncl.ded are s.ch sy/pto/s as persec.tory del.sions 4not directly related to

9ood,incon4r(ent psychotic feat(res: Del.sions or hall.cinations 0hose content does not involve typical depressive the/es of personal inade2.acy ,.ilt disease death nihilis/ or deserved p.nish/ent- $ncl.ded are s.ch sy/pto/s as persec.tory del.sions 4not directly related to depressive the/es9 tho.,ht insertion tho.,ht +roadcastin, and del.sions of control!n partial re)ission: Sy/pto/s of a /aAor depressive episode are present +.t f.ll criteria are not /et or there is a period 0itho.t any si,nificant sy/pto/s of a /aAor depressive episode lastin, less than 7 /onths follo0in, the end of the /aAor depressive episode- 4$f the /aAor depressive episode 0as s.peri/posed on dysthy/ic disorder the dia,nosis of dysthy/ic disorder alone is ,iven once the f.ll criteria for a /aAor depressive episode are no lon,er /et-9 !n f(ll re)ission: D.rin, the past 7 /onths no

S9,!3,": Criteria for Severity/Psychotic/ :e)ission Specifiers for C(rrent 6or 9ost :ecent7 9anic Episode ;ote: Code in fifth di,it- 3ild /oderate severe 0itho.t psychotic feat.res and severe 0ith psychotic feat.res can +e applied only if the criteria are c.rrently /et for a /anic episode- $n partial re/ission and in f.ll re/ission can +e applied to a /anic episode in +ipolar $ disorder only if it is the /ost recent type of /ood episode9ild: 3ini/./ sy/pto/ criteria are /et for a /anic episode9oderate: #;tre/e increase in activity or i/pair/ent in A.d,/entSevere 5itho(t psychotic feat(res: )l/ost contin.al s.pervision re2.ired to prevent physical har/ to self or othersSevere 5ith psychotic feat(res: Del.sions or hall.cinations- $f possi+le specify 0hether the psychotic feat.res are /ood-con,r.ent or /ood-

9ood,con4r(ent psychotic feat(res: Del.sions or hall.cinations 0hose content is entirely consistent 0ith the typical /anic the/es of inflated 0orth po0er kno0led,e identity or special relationship to a deity or fa/o.s personKKK9ood,incon4r(ent psychotic feat(res: Del.sions or hall.cinations 0hose content does not involve typical /anic the/es of inflated 0orth po0er kno0led,e identity or special relationship to a deity or fa/o.s person- $ncl.ded are s.ch sy/pto/s as persec.tory del.sions 4not directly related to ,randiose ideas or the/es9 tho.,ht insertion and del.sions of +ein, controlled!n partial re)ission: Sy/pto/s of a /anic episode are present +.t f.ll criteria are not /et or there is a period 0itho.t any si,nificant sy/pto/s of a /anic episode lastin, less than 7 /onths follo0in, the end of the /anic episode!n f(ll re)ission: D.rin, the past 7 /onths no

).thors: Sadock BenAa/in ?a/es< Sadock Jir,inia )lcott Title: Kaplan & Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry !"th #dition

issociative isorders :es()e +y dr li#a

the essential feat.re of the dissociative disorders is a disr.ption in the .s.ally inte,rated f.nctions of conscio.sness /e/ory identity or perception of the environ/ent- The dist.r+ance /ay +e s.dden or ,rad.al transient or chronicThe DS3-$J-TR dissociative disorders are dissociative identity disorder depersonali%ation disorder dissociative a/nesia dissociative f.,.e and dissociative disorder not other0ise specified 4>*S9-

issociative ')nesia )ccordin, to DS3-$J-TR 4Ta+le 7"-!9 the essential feat.re of dissociative a/nesia is an ina+ility to recall i/portant personal infor/ation .s.ally of a tra./atic or stressf.l nat.re that is too e;tensive to +e e;plained +y nor/al for,etf.lness- The dist.r+ance does not occ.r e;cl.sively d.rin, the co.rse of dissociative identity disorder dissociative f.,.e posttra./atic stress disorder 4PTSD9 ac.te stress disorder or so/ati%ation disorder and does not res.lt fro/ the direct physiolo,ical effects of a s.+stance or a ne.rolo,ical or other ,eneral /edical conditionThis dist.r+ance can +e +ased on ne.ro+iolo,ical chan,es in the +rain ca.sed +y tra./atic stress- The different patterns of

) &=-year-old divorced left-handed /ale +.s dispatcher 0as seen in psychiatric cons.ltation on a /edical .nit- @e had +een ad/itted 0ith an episode of chest disco/fort li,ht headedness and left-ar/ 0eakness- @e had a history of hypertension and had a /edical ad/ission in the past year for ische/ic chest pain altho.,h he had not s.ffered a /yocardial infarction- Psychiatric cons.ltation 0as called +eca.se the patient co/plained of /e/ory loss for the previo.s !7 years +ehavin, and respondin, to the environ/ent as if it 0ere !7 years previo.sly 4e-,- he didn't reco,ni%e his 5-year-old son insisted that he 0as .n/arried and denied recollection of c.rrent events s.ch as the c.rrent president9- Physical and la+oratory findin,s 0ere .nchan,ed fro/ the patient's .s.al +aseline- Brain co/p.ted to/o,raphy 4CT9 scan 0as nor/al*n /ental stat.s e;a/ination the patient displayed intact intellect.al f.nction +.t insisted that the date 0as !7 years earlier denyin, recall of his entire s.+se2.ent personal history and of c.rrent events for the last !7 years- @e 0as perple;ed +y the contradiction +et0een his /e/ory and c.rrent circ./stances- The patient descri+ed a fa/ily history of +r.tal +eatin,s and physical discipline- @e 0as a decorated co/+at veteran altho.,h he descri+ed a/nestic episodes for so/e of his co/+at e;periences$n the /ilitary he had +een a cha/pion ,olden ,love +o;er noted for his po0erf.l left hand@e 0as ed.cated a+o.t his disorder and ,iven the s.,,estion that his /e/ory co.ld ret.rn as he co.ld tolerate it perhaps overni,ht d.rin, sleep or perhaps over a lon,er ti/e- $f this strate,y 0as

#pide/iolo,y Dissociative a/nesia as defined +y DS3$J-TR has +een reported in appro;i/ately ( percent of the ,eneral pop.lation- >o kno0n difference is seen in incidence +et0een /en and 0o/en- Cases ,enerally +e,in to +e reported in late adolescence and ad.lthood- Dissociative a/nesia can +e especially diffic.lt to assess in preadolescent children +eca.se of their /ore li/ited a+ility to descri+e s.+Aective e;perience-

#tiolo,y )/nesia and #;tre/e $ntrapsychic Conflict $n /any cases of ac.te dissociative a/nesia the psychosocial environ/ent o.t of 0hich the a/nesia develops is /assively conflict.al 0ith the patient e;periencin, intolera+le e/otions of sha/e ,.ilt despair ra,e and desperation- These .s.ally res.lt fro/ conflicts over .naccepta+le .r,es or i/p.lses s.ch as intense se;.al s.icidal or violent co/p.lsionsBetrayal Tra./a Betrayal tra./a atte/pts to e;plain a/nesia +y the intensity of tra./a and +y the e;tent that a ne,ative event represents a +etrayal +y a tr.sted needed other- This +etrayal is tho.,ht to infl.ence the 0ay in 0hich the event is processed and re/e/+ered$nfor/ation a+o.t the a+.se is not linked to /ental /echanis/s that control attach/ent and attach/ent +ehavior-

S9,!3,": ia4nostic Criteria for issociative ')nesia The predo/inant dist.r+ance is one or /ore episodes of ina+ility to recall i/portant personal infor/ation .s.ally of a tra./atic or stressf.l nat.re that is too e;tensive to +e e;plained +y ordinary for,etf.lnessThe dist.r+ance does not occ.r e;cl.sively d.rin, the co.rse of dissociative identity disorder dissociative f.,.e posttra./atic stress disorder ac.te stress disorder or so/ati%ation disorder and is not d.e to the direct physiolo,ical effects of a s.+stance 4e-,- a dr., of a+.se a /edication9 or a ne.rolo,ical or other ,eneral /edical condition 4e-,- a/nestic disorder d.e to head tra./a9The sy/pto/s ca.se clinically si,nificant distress or i/pair/ent in social occ.pational or other i/portant areas of f.nctionin,41ro/ )/erican Psychiatric )ssociation- Diagnostic and Statistical Manual of Mental Disorders. &th ed- Te;t rev-

"ypes of issociative ')nesia Docali%ed a/nesia $na+ility to recall events related to a circ./scri+ed period of ti/e Selective a/nesia )+ility to re/e/+er so/e +.t not all of the events occ.rrin, d.rin, a circ./scri+ed period of ti/e :enerali%ed a/nesia 1ail.re to recall one's entire life Contin.o.s a/nesia 1ail.re to recall s.ccessive events as they occ.r Syste/ati%ed a/nesia )/nesia for certain cate,ories of /e/ory s.ch as all /e/ories relatin, to one's fa/ily or to a

/rdinary for4etf(lness @@@'4e,related co4nitive decline ;onpatholo4ical for)s of a)nesia @@@!nfantile and childhood a)nesia @@@')nesia for sleep and drea)in4 @@@>ypnotic a)nesia e)entia eliri() ')nestic disorders ;e(rolo4ical disorders 5ith discrete )e)ory loss episodes @@@Posttra()atic a)nesia @@@"ransient 4lo+al a)nesia @@@')nesia related to sei#(re disorders S(+stance,related a)nesia @@@'lcohol @@@Sedative,hypnotics @@@'nticholiner4ic a4ents @@@Steroids @@@9ari0(ana @@@;arcotic anal4esics @@@Psychedelics @@@Phencyclidine @@@9ethyldopa 6'ldo)et7

ifferential ia4nosis of issociative ')nesia

K>ypo4lyce)ic a4ents

@@@AB,+lockers @@@1ithi() car+onate @@@9any others /ther dissociative disorders @@@ issociative f(4(e @@@ issociative identity disorder @@@ issociative disorder not other5ise specified 'c(te stress disorder Posttra()atic stress disorder So)ati#ation disorder Psychotic episode @@@1ack of )e)ory for psychotic episode 5hen ret(rns to nonpsychotic state 9ood disorder episode @@@1ack of )e)ory for aspects of episode of )ania 5hen depressed and vice versa or 5hen

Dysthy/ia and Cyclothy/ia

Dysthy/ic Disorder )ccordin, to the te;t revision of the fo.rth edition of Dia,nostic and Statistical 3an.al of 3ental Disorders 4DS3-$J-TR9 the /ost typical feat.res of dysthy/ic disorder is the presence of a depressed /ood that lasts /ost of the day and is present al/ost contin.o.slyThere are associated feelin,s of inade2.acy ,.ilt irrita+ility and an,er< 0ithdra0al fro/ society< loss of interest< and inactivity and lack of prod.ctivityThe ter/ dysthy/ia 0hich /eans ill h./ored 0as introd.ced in !65"- Before that ti/e /ost patients no0 classified as havin, dysthy/ic disorder 0ere classified as havin, depressive ne.rosis 4also called ne.rotic depression9-

Dysthy/ic disorder is distin,.ished fro/ /aAor depressive disorder +y the fact that patients co/plain that they have al0ays +een depressedTh.s /ost cases are of early onset +e,innin, in childhood or adolescence and certainly occ.rrin, +y the ti/e patients reach their 7"s- ) late-onset s.+type /.ch less prevalent and not 0ell characteri%ed clinically has +een identified a/on, /iddle-a,ed and ,eriatric pop.lations lar,ely thro.,h epide/iolo,ical st.dies in the co//.nity)ltho.,h dysthy/ia can occ.r as a secondary co/plication of other psychiatric disorders the core concept of dysthy/ic disorder refers to a s.+affective or s.+clinical depressive disorder 0ith 4!9 lo0-,rade chronicity for at least 7 years< 479 insidio.s onset 0ith ori,in often in childhood or adolescence< and 4'9 persistent or inter/ittent co.rse- The fa/ily history of patients 0ith dysthy/ia is typically replete 0ith +oth depressive and +ipolar

#pide/iolo,y Dysthy/ic disorder is co//on a/on, the ,eneral pop.lation and affects = to ( percent of all persons$t is seen a/on, patients in ,eneral psychiatric clinics 0here it affects +et0een one half and one third of all patients- >o ,ender differences are seen for incidence rates- The disorder is /ore co//on in 0o/en yo.n,er than (& years of a,e than in /en of any a,e and is /ore co//on a/on, .n/arried and yo.n, persons and in those 0ith lo0 inco/esDysthy/ic disorder fre2.ently coe;ists 0ith other /ental disorders partic.larly /aAor depressive disorder and in persons 0ith /aAor depressive disorder there is less likelihood of f.ll re/ission +et0een episodes- The patients /ay also have coe;istin, an;iety disorders 4especially panic disorder9 s.+stance a+.se and +orderline personality disorder- The disorder is /ore co//on a/on, those 0ith first-de,ree relatives 0ith /aAor depressive disorder- Patients 0ith dysthy/ic disorder are likely to +e takin, a 0ide ran,e of psychiatric /edications incl.din, antidepressants

#tiolo,y
Biolo,ical 1actors The +iolo,ical +asis for the sy/pto/s of dysthy/ic disorder and /aAor depressive disorder are si/ilar +.t the +iolo,ical +ases for the .nderlyin, pathophysiolo,y in the t0o disorders differ Sleep St.dies Decreased rapid eye /ove/ent 4R#39 latency and increased R#3 density are t0o state /arkers of depression in /aAor depressive disorder that also occ.r in a si,nificant proportion of patients 0ith dysthy/ic disorder

>e.roendocrine St.dies The t0o /ost st.died ne.roendocrine a;es in /aAor depressive disorder and dysthy/ic disorder are the adrenal a;is and the thyroid a;is 0hich have +een tested +y .sin, the de;a/ethasones.ppression test 4DST9 and the thyrotropin-releasin, hor/one 4TR@9sti/.lation test respectively- )ltho.,h the res.lts of st.dies are not a+sol.tely consistent /ost indicate that patients 0ith dysthy/ic disorder are less likely to have a+nor/al res.lts on a DST than are patients 0ith /aAor depressive disorder

Psychosocial 1actors Psychodyna/ic theories a+o.t the develop/ent of dysthy/ic disorder posit that the disorder res.lts fro/ personality and e,o develop/ent and c.l/inates

in diffic.lty adaptin, to adolescence and yo.n, ad.lthood- Karl )+raha/ for e;a/ple tho.,ht that the conflicts of depression center on oraland anal-sadistic traits- )nal traits incl.de e;cessive orderliness ,.ilt and concern for others< they are post.lated to +e a defense a,ainst preocc.pation 0ith anal /atter and 0ith disor,ani%ation hostility and self-preocc.pation) /aAor defense /echanis/ .sed is reaction for/ation- Do0 self-estee/ anhedonia and introversion are often associated 0ith the depressive character

1re.d $n 3o.rnin, and 3elancholia Si,/.nd 1re.d asserted that an interpersonal disappoint/ent early in life can ca.se a v.lnera+ility to depression that leads to a/+ivalent love relationships as an ad.lt< real or threatened losses in ad.lt life then tri,,er depressionPersons s.scepti+le to depression are orally dependent and re2.ire constant narcissistic ,ratification- Bhen deprived of love affection and care they +eco/e clinically depressed< 0hen they e;perience a real loss they internali%e or introAect the lost o+Aect and t.rn their an,er on it and th.s on the/selvesCo,nitive Theory The co,nitive theory of depression also applies to dysthy/ic disorder- $t holds that a disparity +et0een act.al and fantasi%ed sit.ations leads to di/inished self-estee/ and a sense of helplessness- The s.ccess of co,nitive therapy in the treat/ent of so/e patients 0ith dysthy/ic

ia4nosis and Clinical .eat(res

The DS3-$J-TR dia,nosis criteria for dysthy/ic disorder 4Ta+le !=-7!9 stip.late the presence of a depressed /ood /ost of the ti/e for at least 7 years 4or ! year for children and adolescents9- To /eet the dia,nostic criteria a patient sho.ld not have sy/pto/s that are +etter acco.nted for as /aAor depressive disorder and sho.ld never have had a /anic or hypo/anic episode- DS3-$J-TR allo0s clinicians to specify 0hether the onset 0as early 4+efore a,e 7!9 or late 4a,e 7! or older9- DS3-$J-TR also allo0s specification of atypical atypica feat.res in dysthy/ic disorderThe profile of dysthy/ic disorder overlaps 0ith that of /aAor depressive disorder +.t differs fro/ it in that sy/pto/s tend to o.tn./+er si,ns 4/ore s.+Aective than o+Aective depression9- This /eans that dist.r+ances in appetite and li+ido are .ncharacteristic and psycho/otor a,itation or retardation is not o+served- This all translates into a depression 0ith atten.ated sy/pto/atolo,yS.+tle endo,eno.s feat.res are o+served ho0ever: inertia lethar,y and anhedonia that are characteristically 0orse in the /ornin,- Beca.se patients presentin, clinically often fl.ct.ate in and o.t of a /aAor depression the core DS3-$J-TR criteria for dysthy/ic disorder tend to e/phasi%e ve,etative dysf.nction 0hereas the alternative Criterion B for dysthy/ic disorder 4Ta+le !=-7-79 in a DS3-$J-TR appendi; lists co,nitive sy/pto/s-

Dysthy/ic disorder is 2.ite hetero,eneo.s)n;iety is not a necessary part of its clinical pict.re yet dysthy/ic disorder is often dia,nosed in patients 0ith an;iety and pho+ic disordersThat clinical sit.ation is so/eti/es dia,nosed as /i;ed an;iety depressive disorder- 1or ,reater operational clarity it is +est to restrict dysthy/ic disorder to a pri/ary disorder one that cannot +e e;plained +y another psychiatric disorder- The essential feat.res of s.ch pri/ary dysthy/ic disorder incl.de ha+it.al ,loo/ +roodin, lack of Aoy in life and preocc.pation 0ith inade2.acyDysthy/ic disorder then is +est characteri%ed as lon,-standin, fl.ct.atin, lo0-,rade depression e;perienced as part of the ha+it.al self and representin, an accent.ation of traits o+served in the depressive te/pera/ent 4Ta+le !=-7-'9- The clinical pict.re of dysthy/ic disorder is varied 0ith so/e patients proceedin, to /aAor depression 0hereas others /anifest the patholo,y lar,ely at the personality level-

S9,!3,": ia4nostic Criteria for ysthy)ic isorder Depressed /ood for /ost of the day for /ore days than not as indicated either +y s.+Aective acco.nt or o+servation +y others for at least 7 years;ote: $n children and adolescents /ood can +e irrita+le and d.ration /.st +e at least ! yearPresence 0hile depressed of t0o 4or /ore9 of the follo0in,:
L L L L L L poor appetite or overeatin, inso/nia or hyperso/nia lo0 ener,y or fati,.e lo0 self-estee/ poor concentration or diffic.lty /akin, decisions feelin,s of hopelessness

D.rin, the 7-year period 4! year for children or adolescents9 of the dist.r+ance the person has never +een 0itho.t the sy/pto/s in Criteria ) and B for /ore than 7 /onths at a ti/e>o /aAor depressive episode has +een present d.rin, the first 7 years of the dist.r+ance 4! year for children and adolescents9< i-e- the dist.r+ance is not +etter acco.nted for +y chronic /aAor depressive disorder or /aAor depressive disorder in partial re/ission;ote: There /ay have +een a previo.s /aAor depressive episode provided there 0as a f.ll re/ission 4no si,nificant si,ns or sy/pto/s for 7 /onths9 +efore develop/ent of the dysthy/ic disorder- $n addition after the initial 7 years 4! year in children or adolescents9 of dysthy/ic disorder there /ay +e s.peri/posed episodes of /aAor depressive disorder in 0hich case +oth dia,noses /ay +e ,iven 0hen the criteria are /et for a /aAor

There has never +een a /anic episode a /i;ed episode or a hypo/anic episode and criteria have never +een /et for cyclothy/ic disorderThe dist.r+ance does not occ.r e;cl.sively d.rin, the co.rse of a chronic psychotic disorder s.ch as schi%ophrenia or del.sional disorderThe sy/pto/s are not d.e to the direct physiolo,ical effects of a s.+stance 4e-,- a dr., of a+.se a /edication9 or a ,eneral /edical condition 4e-,- hypothyroidis/9The sy/pto/s ca.se clinically si,nificant distress or i/pair/ent in social occ.pational or other i/portant areas of f.nctionin,Specify if: KKKEarly onset: if onset is +efore a,e 7! years KKK1ate onset: if onset is a,e 7! years or older Specify 4for /ost recent 7 years of dysthy/ic disorder9 if KKKCith atypical feat(res

S9,!3,": 'lternative :esearch Criterion B for ysthy)ic isorder Presence 0hile depressed of three 4or /ore9 of the follo0in,:

L lo0 self-estee/ or self-confidence or feelin,s of inade2.acy L feelin,s of pessi/is/ despair or hopelessness L ,enerali%ed loss of interest or pleas.re L social 0ithdra0al L chronic fati,.e or tiredness L feelin,s of ,.ilt +roodin, a+o.t the past L s.+Aective feelin,s of irrita+ility or e;cessive an,er L decreased activity effectiveness or prod.ctivity L diffic.lty in thinkin, reflected +y poor concentration poor /e/ory or indecisiveness

Deon is a &=-year-old postal e/ployee 0ho 0as eval.ated at a clinic speciali%in, in the treat/ent of depression- @e clai/s to have felt constantly depressed since the first ,rade 0itho.t a period of nor/al /ood for /ore than a fe0 days at a ti/e- @is depression has +een acco/panied +y lethar,y little or no interest or pleas.re in anythin, tro.+le concentratin, and feelin,s of inade2.acy pessi/is/ and resentf.lness@is only periods of nor/al /ood occ.r 0hen he is ho/e alone listenin, to /.sic or 0atchin, TJ*n f.rther 2.estionin, Deon reveals that he cannot ever re/e/+er feelin, co/forta+le socially- #ven +efore kinder,arten if he 0as asked to speak in front of a ,ro.p of his parents' friends his /ind 0o.ld ,o +lank@e felt over0hel/in, an;iety at children's social f.nctions s.ch as +irthday parties 0hich he either avoided or if he 0ent attended in total silence- @e co.ld ans0er 2.estions in class only if he 0rote do0n the ans0ers in advance< even then he fre2.ently /./+led and co.ldn't ,et the ans0er o.t- @e /et ne0 children 0ith his eyes lo0ered fearin, their scr.tiny e;pectin, to feel h./iliated and e/+arrassed- @e 0as

)s he ,re0 .p Deon had a co.ple of nei,h+orhood play/ates +.t he never had a +est friend-@is school ,rades 0ere ,ood +.t s.ffered 0hen oral classroo/ participation 0as e;pected)s a teena,er he 0as terrified of ,irls and to this day has never ,one on a date or even asked a ,irl for a date- This +others hi/ altho.,h he is so often depressed that he feels he has little ener,y or interest in datin,Deon attended colle,e and did 0ell for a 0hile then dropped o.t as his ,rades slipped- @e re/ained very self-conscio.s and terrified of /eetin, stran,ers- @e had tro.+le findin, a Ao+ +eca.se he 0as .na+le to ans0er 2.estions in intervie0s- @e 0orked at a fe0 Ao+s for 0hich only a 0ritten test 0as re2.ired@e passed a Civil Service e;a/ at a,e 7& and 0as offered a Ao+ in the post office on the evenin, shift- @e enAoyed this Ao+ as it involved little contact 0ith others- @e 0as offered +.t ref.sed several pro/otions +eca.se he feared the social press.res- )ltho.,h +y no0 he s.pervises a n./+er of e/ployees he still finds it diffic.lt to ,ive instr.ctions even to people he has kno0n for years- @e has no friends and avoids all invitations to sociali%e 0ith co-0orkers- D.rin, the past several years he has tried several therapies to help hi/ ,et over his shyness and depressionDeon has never e;perienced s.dden an;iety or a panic attack in social sit.ations or at other ti/es- Rather his an;iety ,rad.ally +.ilds to a constant hi,h level in anticipation of social sit.ations- @e has never e;perienced any psychotic sy/pto/s-

Depressive :loo/y incapa+le of f.n co/plainin, Pessi/istic and ,iven to +roodin, :.ilt-prone lo0 selfestee/ and preocc.pied 0ith inade2.acy or fail.re $ntroverted 0ith restricted social life Sl.,,ish livin, a life o.t of action 1e0 +.t constant interests Passive Relia+le dependa+le and devoted

@yperthy/ic Cheerf.l and e;.+erant *veropti/istic and carefree *verconfident selfass.red +oastf.l and ,randiose #;troverted and people seekin, @i,h ener,y level f.ll of plans Jersatile 0ith +road interests *verinvolved and /eddleso/e Eninhi+ited and sti/.l.s

Dysthy/ic Jariants Dysthy/ia is not .nco//on in patients 0ith chronically disa+lin, physical disorders partic.larly a/on, elderly ad.lts- Dysthy/ia-like clinically si,nificant s.+threshold depression lastin, ( or /ore /onths has also +een descri+ed in ne.rolo,ical conditions incl.din, stroke- )ccordin, to a recent Borld @ealth *r,ani%ation 4B@*9 conference this condition a,,ravates the pro,nosis of the .nderlyin, ne.rolo,ical disease and therefore deserves phar/acotherapyProspective st.dies on children have revealed an episodic co.rse of dysthy/ia 0ith re/issions e;acer+ations and event.al co/plications +y /aAor depressive episodes != to 7" percent of 0hich /i,ht even pro,ress to hypo/anic /anic or /i;ed episodes postp.+erty- Persons 0ith dysthy/ic disorder presentin, clinically as ad.lts tend to p.rs.e a chronic .nipolar co.rse that /ay or /ay not +e co/plicated +y /aAor depression- They rarely develop spontaneo.s hypo/ania or /ania- Bhen treated 0ith antidepressants ho0ever so/e of the/ /ay develop

Differential Dia,nosis The differential dia,nosis for dysthy/ic disorder is essentially identical to that for /aAor depressive disorder- 3any s.+stances and /edical illnesses can ca.se chronic depressive sy/pto/s- T0o disorders are partic.larly i/portant to consider in the differential dia,nosis of dysthy/ic disorderQRU/inor depressive disorder and rec.rrent +rief depressive disorder3inor Depressive Disorder 3inor depressive disorder 4disc.ssed in Section !=-'9 is characteri%ed +y episodes of depressive sy/pto/s that are less severe than those seen in /aAor depressive disorder- The difference +et0een dysthy/ic disorder and /inor depressive disorder is pri/arily the episodic nat.re of the sy/pto/s in the latter- Bet0een episodes patients 0ith /inor depressive disorder have a e.thy/ic /ood 0hereas patients 0ith dysthy/ic disorder have virt.ally no e.thy/ic periods-

Rec.rrent Brief Depressive Disorder Rec.rrent +rief depressive disorder 4disc.ssed in Section !=-'9 is characteri%ed +y +rief periods 4less than 7 0eeks9 d.rin, 0hich depressive episodes are present- Patients 0ith the disorder 0o.ld /eet the dia,nostic criteria for /aAor depressive disorder if their episodes lasted lon,er- Patients 0ith rec.rrent +rief depressive disorder differ fro/ patients 0ith dysthy/ic disorder on t0o co.nts: They have an episodic disorder and their sy/pto/s are /ore severe-

Do.+le Depression )n esti/ated &" percent of patients 0ith /aAor depressive disorder also /eet the criteria for dysthy/ic disorder a co/+ination often referred to as do.+le depression)vaila+le data s.pport the concl.sion that patients 0ith do.+le depression have a poorer pro,nosis than patients 0ith only /aAor depressive disorder- The treat/ent of patients 0ith do.+le depression sho.ld +e directed to0ard +oth disorders +eca.se the resol.tion of the sy/pto/s of /aAor depressive episode still leaves these patients 0ith si,nificant psychiatric i/pair/ent )lcohol and S.+stance )+.se Patients 0ith dysthy/ic disorder co//only /eet the dia,nostic criteria for a s.+stance-related disorder- This co/or+idity can +e lo,ical< patients 0ith dysthy/ic disorder tend to develop copin, /ethods for their chronically depressed state that involve s.+stance a+.se- Therefore they are likely to .se alcohol sti/.lants s.ch as cocaine or /ariA.ana the choice perhaps dependin, pri/arily on a patient's social conte;t- The presence of a co/or+id dia,nosis of s.+stance a+.se presents a dia,nostic dile//a for

Co.rse and Pro,nosis )+o.t =" percent of patients 0ith dysthy/ic disorder e;perience an insidio.s onset of sy/pto/s +efore a,e 7=- Despite the early onset patients often s.ffer 0ith the sy/pto/s for a decade +efore seekin, psychiatric help and /ay consider early-onset dysthy/ic disorder si/ply part of life- Patients 0ith an early onset of sy/pto/s are at risk for either /aAor depressive disorder or +ipolar $ disorder in the co.rse of their disorder- St.dies of patients 0ith the dia,nosis of dysthy/ic disorder indicate that a+o.t 7" percent pro,ressed to /aAor depressive disorder != percent to +ipolar $$ disorder and less than = percent to +ipolar $ disorderThe pro,nosis for patients 0ith dysthy/ic disorder varies- )ntidepressive a,ents and specific types of psychotherapies 4e-,- co,nitive and +ehavior therapies9 have positive effects on the co.rse and pro,nosis of dysthy/ic disorder- The availa+le data a+o.t previo.sly availa+le treat/ents indicate that only !" to != percent of patients are in re/ission ! year

Treat/ent @istorically patients 0ith dysthy/ic disorder either received no treat/ent or 0ere seen as candidates for lon,-ter/ insi,ht-oriented psychotherapy- Conte/porary data offer the /ost o+Aective s.pport for co,nitive therapy +ehavior therapy and phar/acotherapy- The co/+ination of phar/acotherapy and so/e for/ of psychotherapy /ay +e the /ost effective treat/ent for the disorder Co,nitive Therapy Co,nitive therapy is a techni2.e in 0hich patients are ta.,ht ne0 0ays of thinkin, and +ehavin, to replace fa.lty ne,ative attit.des a+o.t the/selves the 0orld and the f.t.re- $t is a short-ter/ therapy pro,ra/ oriented to0ard

Behavior Therapy Behavior therapy for depressive disorders is +ased on the theory that depression is ca.sed +y a loss of positive reinforce/ent as a res.lt of separation death or s.dden environ/ental chan,e- The vario.s treat/ent /ethods foc.s on specific ,oals to increase activity to provide pleasant e;periences and to teach patients ho0 to rela;- )lterin, personal +ehavior in depressed patients is +elieved to +e the /ost effective 0ay to chan,e the associated depressed tho.,hts and feelin,s- Behavior therapy is often .sed to treat the learned helplessness of so/e patients 0ho see/ to /eet every life challen,e 0ith a sense of i/potence-

$nsi,ht-*riented 4Psychoanalytic9 Psychotherapy $ndivid.al insi,ht-oriented psychotherapy is the /ost co//on treat/ent /ethod for dysthy/ic disorder and /any clinicians consider it the treat/ent of choice- The psychotherape.tic approach atte/pts to relate the develop/ent and /aintenance of depressive sy/pto/s and /aladaptive personality feat.res to .nresolved conflicts fro/ early childhood- $nsi,ht into depressive e2.ivalents 4e-,- s.+stance a+.se9 or into childhood disappoint/ents as antecedents to ad.lt depression can +e ,ained thro.,h treat/ent- )/+ivalent c.rrent relationships 0ith parents friends and others in the patient's c.rrent life are e;a/ined- Patients' .nderstandin, of ho0 they try to ,ratify an e;cessive need for o.tside approval to

$nterpersonal Therapy $n interpersonal therapy for depressive disorders a patient's c.rrent interpersonal e;periences and 0ays of copin, 0ith stress are e;a/ined to red.ce depressive sy/pto/s and to i/prove selfestee/- $nterpersonal therapy lasts for a+o.t !7 to !( 0eekly sessions and can +e co/+ined 0ith antidepressant /edication1a/ily and :ro.p Therapies 1a/ily therapy /ay help +oth the patient and the patient's fa/ily deal 0ith the sy/pto/s of the disorder especially 0hen a +iolo,ically +ased s.+affective syndro/e see/s to +e present:ro.p therapy /ay help 0ithdra0n patients learn ne0 0ays to overco/e their interpersonal pro+le/s in social sit.ations-

Phar/acotherapy Beca.se of lon,-standin, and co//only held theoretical +eliefs that dysthy/ic disorder is pri/arily a psycholo,ically deter/ined disorder /any clinicians avoid prescri+in, antidepressants for patients< ho0ever /any st.dies have sho0n therape.tic s.ccess 0ith antidepressants- The data ,enerally indicate that selective serotonin re.ptake inhi+itors 4SSR$s9 venlafa;ine and +.propion are an effective treat/ent for patients 0ith dysthy/ic disorder- 3onoa/ine o;idase inhi+itors 43)*$s9 are effective in a s.+,ro.p of patients 0ith dysthy/ic disorder a ,ro.p 0ho /ay also respond to the A.dicio.s .se of a/pheta/ines @ospitali%ation @ospitali%ation is .s.ally not indicated for patients 0ith dysthy/ic disorder +.t partic.larly severe sy/pto/s /arked social or professional incapacitation the need for e;tensive dia,nostic

Cyclothy/ic Disorder Cyclothy/ic disorder is sy/pto/atically a /ild for/ of +ipolar $$ disorder characteri%ed +y episodes of hypo/ania and /ild depression$n DS3-$J-TR cyclothy/ic disorder is defined as a chronic fl.ct.atin, dist.r+ance 0ith /any periods of hypo/ania and of depressionThe disorder is differentiated fro/ +ipolar $$ disorder 0hich is characteri%ed +y the presence of /aAor 4not /inor9 depressive and hypo/anic episodes- )s 0ith dysthy/ic disorder the incl.sion of cyclothy/ic disorder 0ith the /ood disorders i/plies a relation pro+a+ly +iolo,ical to +ipolar $ disorder- So/e psychiatrists ho0ever consider cyclothy/ic disorder to have no +iolo,ical co/ponent and to res.lt fro/ chaotic o+Aect relations early in life

Conte/porary concept.ali%ation of cyclothy/ic disorder is +ased to so/e e;tent on the o+servations of #/il Kraepelin and K.rt Schneider that one third to t0o thirds of patients 0ith /ood disorders e;hi+it personality disordersKraepelin descri+ed fo.r types of personality disorders: depressive 4,loo/y9 /anic 4cheerf.l and .ninhi+ited9 irrita+le 4la+ile and e;plosive9 and cyclothy/ic- @e descri+ed the irrita+le personality as si/.ltaneo.sly depressive and /anic and the cyclothy/ic personality as the alternation of the depressive and /anic personalities-

#pide/iolo,y Patients 0ith cyclothy/ic disorder /ay constit.te fro/ ' to = percent of all psychiatric o.tpatients perhaps partic.larly those 0ith si,nificant co/plaints a+o.t /arital and interpersonal diffic.lties- $n the ,eneral pop.lation the lifeti/e prevalence of cyclothy/ic disorder is esti/ated to +e a+o.t ! percent- This fi,.re is pro+a+ly lo0er than the act.al prevalence +eca.se as 0ith patients 0ith +ipolar $ disorder the patients /ay not +e a0are that they have a psychiatric pro+le/Cyclothy/ic disorder as 0ith dysthy/ic disorder fre2.ently coe;ists 0ith +orderline personality disorder- )n esti/ated !" percent of o.tpatients and 7" percent of inpatients 0ith +orderline personality disorder have a coe;istin, dia,nosis of cyclothy/ic disorder- The fe/ale-to-/ale ratio in cyclothy/ic disorder is a+o.t ' to 7 and =" to 8= percent of all patients have an onset +et0een a,es != and 7=-

 #tiolo,y )s

0ith dysthy/ic disorder controversy e;ists a+o.t 0hether cyclothy/ic disorder is related to the /ood disorders either +iolo,ically or psycholo,ically- So/e researchers have post.lated that cyclothy/ic disorder has a closer relation to +orderline personality disorder than to the /ood disorders- Despite these controversies the preponderance of +iolo,ical and ,enetic data favors the idea of cyclothy/ic disorder as a +ona fide /ood disorder-

Biolo,ical 1actors )+o.t '" percent of all patients 0ith cyclothy/ic disorder have positive fa/ily histories for +ipolar $ disorder< this rate is si/ilar to the rate for patients 0ith +ipolar $ disorder- 3oreover the pedi,rees of fa/ilies 0ith +ipolar $ disorder often contain ,enerations of patients 0ith +ipolar $ disorder linked +y a ,eneration 0ith cyclothy/ic disorder- Conversely the prevalence of cyclothy/ic disorder in the relatives of patients 0ith +ipolar $ disorder is /.ch hi,her than the prevalence of cyclothy/ic disorder either in the relatives of patients 0ith other /ental disorders or in persons 0ho are /entally healthy- The o+servations that a+o.t one third of patients 0ith cyclothy/ic disorder s.+se2.ently have /aAor /ood disorders that they are partic.larly sensitive to antidepressant-ind.ced hypo/ania and that a+o.t (" percent respond to lithi./ add f.rther s.pport to the idea of cyclothy/ic disorder as a /ild or atten.ated for/ of +ipolar $$

Psychosocial 1actors 3ost psychodyna/ic theories post.late that the develop/ent of cyclothy/ic disorder lies in tra./as and fi;ations d.rin, the oral sta,e of infant develop/ent- 1re.d hypothesi%ed that the cyclothy/ic state is the e,o's atte/pt to overco/e a harsh and p.nitive s.pere,o@ypo/ania is e;plained psychodyna/ically as the lack of self-criticis/ and an a+sence of inhi+itions occ.rrin, 0hen a depressed person thro0s off the +.rden of an overly harsh s.pere,o- The /aAor defense /echanis/ in hypo/ania is denial +y 0hich the patient avoids e;ternal pro+le/s and internal feelin,s of depressionPatients 0ith cyclothy/ic disorder are characteri%ed +y periods of depression alternatin, 0ith periods of hypo/ania- Psychoanalytic e;ploration reveals that s.ch patients defend the/selves a,ainst .nderlyin, depressive the/es 0ith their e.phoric or hypo/anic periods@ypo/ania is fre2.ently tri,,ered +y a profo.nd interpersonal loss- The false e.phoria ,enerated in s.ch instances is a patient's 0ay to deny dependence on love o+Aects and si/.ltaneo.sly disavo0in, any a,,ression or destr.ctiveness that /ay have contri+.ted to the loss of the loved person-

Dia,nosis and Clinical 1eat.res )ltho.,h /any patients seek psychiatric help for depression their pro+le/s are often related to the chaos that their /anic episodes have ca.sed- Clinicians /.st consider a dia,nosis of cyclothy/ic disorder 0hen a patient appears 0ith 0hat /ay see/ to +e sociopathic +ehavioral pro+le/s3arital diffic.lties and insta+ility in relationships are co//on co/plaints +eca.se patients 0ith cyclothy/ic disorder are often pro/isc.o.s and irrita+le 0hile in /anic and /i;ed states- )ltho.,h there are anecdotal reports of increased prod.ctivity and creativity 0hen patients are hypo/anic /ost clinicians report that their patients P-=(8

S9,!3,": ia4nostic Criteria for Cyclothy)ic isorder 1or at least 7 years the presence of n./ero.s periods 0ith hypo/anic sy/pto/s and n./ero.s periods 0ith depressive sy/pto/s that do not /eet criteria for a /aAor depressive episode- ;ote: $n children and adolescents the d.ration /.st +e at least ! year D.rin, the a+ove 7-year period 4! year in children and adolescents9 the person has not +een 0itho.t the sy/pto/s in Criterion ) for /ore than 7 /onths at a ti/e >o /aAor depressive episode /anic episode or /i;ed episode has +een present d.rin, the first 7 years of the dist.r+ance;ote: )fter the initial 7 years 4! year in children and adolescents9 of cyclothy/ic disorder there /ay +e s.peri/posed /anic or /i;ed episodes 4in 0hich case +oth +ipolar $ disorder and cyclothy/ic disorder /ay +e dia,nosed9 or /aAor depressive episodes 4in 0hich case

The sy/pto/s in Criterion ) are not +etter acco.nted for +y schi%oaffective disorder and are not s.peri/posed on schi%ophrenia schi%ophrenifor/ disorder del.sional disorder or psychotic disorder not other0ise specifiedThe sy/pto/s are not d.e to the direct physiolo,ical effects of a s.+stance 4e-,a dr., of a+.se a /edication9 or a ,eneral /edical condition 4e-,hyperthyroidis/9The sy/pto/s ca.se clinically si,nificant distress or i/pair/ent in social occ.pational or other i/portant areas of

Si,ns and Sy/pto/s The sy/pto/s of cyclothy/ic disorder are identical to the sy/pto/s of +ipolar $$ disorder e;cept that they are ,enerally less severe- *n occasion ho0ever the sy/pto/s /ay +e e2.ally severe +.t of shorter d.ration than those seen in +ipolar $$ disorder- )+o.t half of all patients 0ith cyclothy/ic disorder have depression as their /aAor sy/pto/ and these patients are /ost likely to seek psychiatric help 0hile depressed- So/e patients 0ith cyclothy/ic disorder have pri/arily hypo/anic sy/pto/s and are less likely to cons.lt a psychiatrist than are pri/arily depressed patients- )l/ost all patients 0ith cyclothy/ic disorder have periods of /i;ed sy/pto/s 0ith /arked irrita+ility3ost patients 0ith cyclothy/ic disorder seen +y psychiatrists have not s.cceeded in their professional and social lives as a res.lt of their disorder +.t a fe0 have +eco/e hi,h achievers 0ho have 0orked especially lon, ho.rs and have re2.ired little sleep- So/e persons' a+ility to control the sy/pto/s of the disorder s.ccessf.lly depends on /.ltiple individ.al social and c.lt.ral attri+.tesThe lives of /ost patients 0ith cyclothy/ic disorder are diffic.ltThe cycles of the disorder tend to +e /.ch shorter than those in +ipolar $ disorder- $n cyclothy/ic disorder the chan,es in /ood are irre,.lar and a+r.pt and so/eti/es occ.r 0ithin ho.rs- The .npredicta+le nat.re of the /ood chan,es prod.ces ,reat stressPatients often feel that their /oods are o.t of control- $n irrita+le /i;ed periods they /ay +eco/e involved in .nprovoked

) 76-year-old car sales/an 0as referred +y his ,irlfriend a psychiatric n.rse 0ho s.spected he had a /ood disorder even tho.,h the patient 0as rel.ctant to ad/it that he /i,ht +e a /oody person- )ccordin, to hi/ since a,e !& he has e;perienced repeated alternatin, cycles that he ter/s ,ood ti/es and +ad ti/es-D.rin, a +ad period .s.ally lastin, & to 8 days he oversleeps !" to !& ho.rs daily lacks ener,y confidence and /otivation A.st ve,etatin, as he p.ts it- *ften he a+r.ptly shifts characteristically .pon 0akin, .p in the /ornin, to a '-day to &day stretch of overconfidence hei,htened social a0areness pro/isc.ity and sharpened thinkin, Thin,s 0o.ld flash in /y /ind- )t s.ch ti/es he ind.l,es in alcohol to enhance the e;perience +.t also to help hi/ sleep- *ccasionally the ,ood periods last 8 to !" days +.t c.l/inate in irrita+le and hostile o.t+.rsts 0hich often herald the transition +ack to another period of +addays- @e ad/its to fre2.ent .se of /ariA.ana 0hich he clai/s helps hi/ adA.st to daily ro.tines$n school )s and Bs alternated 0ith Cs and Ds 0ith the res.lt that the patient 0as considered a +ri,ht st.dent 0hose perfor/ance 0as /ediocre overall +eca.se of .nsta+le /otivation- )s a car sales/an his perfor/ance has also +een .neven 0ith ,ood days cancelin, o.t the QRV+ad days< yet even d.rin, his ,ood days he is so/eti/es ar,./entative 0ith c.sto/ers and loses sales that appeared s.re- )ltho.,h considered a char/in, /an in /any social circles he alienates friends 0hen he is hostile and irrita+le@e typically acc./.lates social o+li,ations d.rin, the +ad days

So/atofor/ Disorders Kaplan & Sadock's Synopsis of Psychiatry

#dit dr li%a

Seven so/atofor/ disorders are listed in the revised fo.rth edition of the Dia,nostic and Statistical 3an.al of 3ental Disorders 4DS3-$J-TR9: 4!9 so/ati%ation disorder characteri%ed +y /any physical co/plaints affectin, /any or,an syste/s< 479 conversion disorder characteri%ed +y one or t0o ne.rolo,ical co/plaints< 4'9 hypochondriasis characteri%ed less +y a foc.s on sy/pto/s than +y patients' +eliefs that they have a specific disease< 4&9 +ody dys/orphic disorder characteri%ed +y a false +elief or e;a,,erated perception that a +ody part is defective< 4=9 pain disorder characteri%ed +y sy/pto/s of pain that are either solely related to or si,nificantly e;acer+ated +y psycholo,ical factors< 4(9 .ndifferentiated so/atofor/ disorder 0hich incl.des so/atofor/ disorders not other0ise descri+ed that have +een present for ( /onths or lon,er< and 489 so/atofor/ disorder not other0ise specified 0hich

So/ati%ation Disorder So/ati%ation disorder is an illness of /.ltiple so/atic co/plaints in /.ltiple or,an syste/s that occ.rs over a period of several years and res.lts in si,nificant i/pair/ent or treat/ent seekin, or +oth- So/ati%ation disorder is the prototypic so/atofor/ disorder and has the +est evidence of any of the so/atofor/ disorders for +ein, a sta+le and relia+ly /eas.red entity over /any years in individ.als 0ith the disorder- So/ati%ation disorder differs fro/ other so/atofor/ disorders +eca.se of the /.ltiplicity of the co/plaints and the /.ltiple or,an syste/s 4e-,,astrointestinal and ne.rolo,ical9 that are affected- The disorder is chronic and is associated 0ith si,nificant psycholo,ical distress i/paired social and occ.pational f.nctionin, and e;cessive /edical-help-seekin, +ehaviorSo/ati%ation disorder has +een reco,ni%ed since the ti/e of ancient #,ypt- )n early na/e for so/ati%ation disorder 0as hysteria a condition incorrectly tho.,ht to affect only 0o/en4The 0ord hysteria is derived fro/ the :reek 0ord for .ter.s hystera-9 $n the !8th cent.ry Tho/as Sydenha/ reco,ni%ed that psycholo,ical factors 0hich he called QRVantecedent sorro0s QR 0ere involved in the patho,enesis of the sy/pto/s- $n !5=6 Pa.l Bri2.et a 1rench physician o+served the /.ltiplicity of sy/pto/s and affected or,an syste/s and co//ented on the .s.ally chronic co.rse of the disorder- Beca.se of these clinical o+servations the disorder 0as called QRVBri2.et's syndro/eQR .ntil the ter/ so/ati%ation disorder +eca/e the standard in the Enited States-

So)ati#ation disorder, Polysy)pto)atic Rec.rrent and chronic Sickly +y history Wo.n, a,e 1e/ale predo/inance 7" to ! 1a/ilial pattern =T-S!"T incidence in pri/ary care pop.lations - Revie0 of syste/s prof.sely positive 3.ltiple clinical contacts Polys.r,ical -Therape.tic alliance Re,.lar appoint/ents Crisis intervention Conversion disorder, 9onosy)pto)atic 3ostly ac.te Si/.lates disease @i,hlyprevalent 1e/ale predo/inance Wo.n, a,e R.ral and lo0 social class Dittle-ed.cated and psycholo,ically .nsophisticated - Si/.lation inco/pati+le 0ith kno0n physiolo,ical /echanis/s or anato/yS.,,estion and pers.asion 3.ltiple techni2.es>ypochondriasis Disease concern or preocc.pation Previo.s physical disease 3iddle or old a,e 3ale-fe/ale ratio e2.alDisease conviction a/plifies sy/pto/s *+sessional Doc./ent sy/pto/s Psychosocial revie0 Psychotherape.tBody dys)orphic disorder S.+Aective feelin,s of .,liness or concern 0ith +ody defect )dolescence or yo.n, ad.lt 1e/ale predo/inance - Pervasive +odily concerns -Therape.tic alliance Stress /ana,e/ent Psychotherapies )ntidepressant /edications Pain disorder Pain syndro/e si/.lated 1e/ale predo/inance 7 to ! *lder: &th or =th decade 1a/ilial pattern Ep to &"T of pain pop.lations- Si/.lation or intensity inco/pati+le 0ith kno0n physiolo,ical /echanis/s or anato/y Therape.tic alliance Redefine ,oals of treat/ent )ntidepressant /edications

Psychosocial 1actors The ca.se of so/ati%ation disorder is .nkno0nPsychosocial for/.lations of the ca.se involve interpretations of the sy/pto/s as social co//.nication 0hose res.lt is to avoid o+li,ations 4e-,- ,oin, to a Ao+ a person does not like9 to e;press e/otions 4e-,- an,er at a spo.se9 or to sy/+oli%e a feelin, or a +elief 4e-,- a pain in the ,.t9- Strict psychoanalytic interpretations of sy/pto/s rest on the hypothesis that the sy/pto/s s.+stit.te for repressed instinct.al i/p.lses ) +ehavioral perspective on so/ati%ation disorder e/phasi%es that parental teachin, parental e;a/ple and ethnic /ores /ay teach so/e children to so/ati%e /ore than others- $n addition so/e patients 0ith so/ati%ation disorder co/e fro/ .nsta+le ho/es and have +een physically a+.sed- Social c.lt.ral and ethnic factors /ay also +e involved in the develop/ent of sy/pto/s-

Biolo,ical 1actors So/e st.dies point to a ne.ropsycholo,ical +asis for so/ati%ation disorder- These st.dies propose that the patients have characteristic attention and co,nitive i/pair/ents that res.lt in the fa.lty perception and assess/ent of so/atosensory inp.ts- The reported i/pair/ents incl.de e;cessive distracti+ility ina+ility to ha+it.ate to repetitive sti/.li ,ro.pin, of co,nitive constr.cts on an i/pressionistic +asis partial and circ./stantial associations and lack of selectivity as indicated in so/e st.dies of evoked potentials) li/ited n./+er of +rain-i/a,in, st.dies have reported decreased /eta+olis/ in the frontal

:enetics :enetic data indicate that in at least so/e fa/ilies the trans/ission of so/ati%ation disorder has ,enetic co/ponents So/ati%ation disorder tends to r.n in fa/ilies and occ.rs in !" to 7" percent of the first-de,ree fe/ale relatives of pro+ands of patients 0ith so/ati%ation disorder- Bithin these fa/ilies first-de,ree /ale relatives are s.scepti+le to s.+stance a+.se and antisocial personality disorder- *ne st.dy also reported a concordance rate of 76 percent in /ono%y,otic t0ins and !" percent in di%y,otic t0ins an indication of a ,enetic effect- The /ale relatives of 0o/en 0ith so/ati%ation disorder sho0 an increased risk of antisocial personality disorder and s.+stance-related disorders- @avin, a +iolo,ical or adoptive parent 0ith any of these three disorders increases the risk of developin, antisocial personality disorder a s.+stancerelated disorder or so/ati%ation disorder-

Cytokines Cytokines are )essen4er )olec(les that the i))(ne syste) (ses to co))(nicate 5ithin itself and 5ith the nervo(s syste), incl(din4 the +rain* E<a)ples of cytokines are interle(kins, t()or necrosis factor, and interferons* So)e preli)inary e<peri)ents indicate that cytokines contri+(te to so)e of the nonspecific sy)pto)s of disease, s(ch as hyperso)nia, anore<ia, fati4(e, and depression* "he hypothesis that a+nor)al re4(lation of the cytokine syste) )ay res(lt in so)e of the sy)pto)s seen in so)atofor) disorders is (nder investi4ation*

ia4nosis .or the dia4nosis of so)ati#ation disorder, S9,!3,": re8(ires onset of sy)pto)s +efore a4e %0 6"a+le 1D,-7* (rin4 the co(rse of the disorder, patients )(st have co)plained of at least fo(r pain sy)pto)s, t5o 4astrointestinal sy)pto)s, one se<(al sy)pto), and one pse(done(rolo4ical sy)pto), none of 5hich is co)pletely e<plained +y physical or la+oratory e<a)inations*

S9,!3,": ia4nostic Criteria for So)ati#ation isorder

' history of )any physical co)plaints +e4innin4 +efore a4e %0 years that occ(r over a period of several years and res(lt in treat)ent +ein4 so(4ht or si4nificant i)pair)ent in social, occ(pational, or other i)portant areas of f(nctionin4* Each of the follo5in4 criteria )(st have +een )et, 5ith individ(al sy)pto)s occ(rrin4 at any ti)e d(rin4 the co(rse of the dist(r+ance: fo(r pain sy)pto)s: a history of pain related to at least fo(r different sites or f(nctions 6e*4*, head, a+do)en, +ack, 0oints, e<tre)ities, chest, rect(), d(rin4 )enstr(ation, d(rin4 se<(al interco(rse, or d(rin4 (rination7 L t5o 4astrointestinal sy)pto)s: a history of at least t5o 4astrointestinal sy)pto)s other than pain 6e*4*, na(sea, +loatin4, vo)itin4 other than d(rin4 pre4nancy, diarrhea, or intolerance of several different foods7 L one se<(al sy)pto): a history of at least one se<(al or reprod(ctive sy)pto) other than pain 6e*4*, se<(al indifference, erectile or e0ac(latory dysf(nction, irre4(lar )enses, e<cessive )enstr(al +leedin4, vo)itin4 thro(4ho(t pre4nancy7

L one pse(done(rolo4ical sy)pto): a history of at least one sy)pto) or deficit s(44estin4 a ne(rolo4ical condition not li)ited to pain 6conversion sy)pto)s s(ch as i)paired coordination or +alance, paralysis or locali#ed 5eakness, diffic(lty s5allo5in4 or l()p in throat, aphonia, (rinary retention, hall(cinations, loss of to(ch or pain sensation, do(+le vision, +lindness, deafness, sei#(resE dissociative sy)pto)s s(ch as a)nesiaE or loss of conscio(sness other than faintin47

Either 617 or 6-7:

L after appropriate investi4ation, each of the sy)pto)s in Criterion B cannot +e f(lly e<plained +y a kno5n 4eneral )edical condition or the direct effects of a s(+stance 6e*4*, a dr(4 of a+(se, a )edication7 L 5hen there is a related 4eneral )edical condition, the physical co)plaints or res(ltin4 social or occ(pational i)pair)ent are in e<cess of 5hat 5o(ld +e e<pected fro) the history, physical e<a)ination, or la+oratory findin4s

"he sy)pto)s are not intentionally prod(ced or fei4ned 6as in factitio(s disorder or )alin4erin47*

Clinical .eat(res Patients 0ith so/ati%ation disorder have /any so/atic co/plaints and lon, co/plicated /edical histories- >a.sea and vo/itin, 4other than d.rin, pre,nancy9 diffic.lty s0allo0in, pain in the ar/s and le,s shortness of +reath .nrelated to e;ertion a/nesia and co/plications of pre,nancy and /enstr.ation are a/on, the /ost co//on sy/pto/sPatients fre2.ently +elieve that they have +een sickly /ost of their lives- Pse.done.rolo,ical sy/pto/s s.,,est +.t are not patho,no/onic of a ne.rolo,ical disorder- )ccordin, to DS3$J-TR they incl.de i/paired coordination or +alance paralysis or locali%ed 0eakness diffic.lty s0allo0in, or l./p in throat aphonia .rinary retention hall.cinations loss of to.ch or pain sensation do.+le vision +lindness deafness sei%.res or

Psycholo,ical distress and interpersonal pro+le/s are pro/inent< an;iety and depression are the /ost prevalent psychiatric conditions- S.icide threats are co//on +.t act.al s.icide is rare- $f s.icide does occ.r it is often associated 0ith s.+stance a+.sePatients' /edical histories are often circ./stantial va,.e i/precise inconsistent and disor,ani%edPatients classically 4+.t not al0ays9 descri+e their co/plaints in a dra/atic e/otional and e;a,,erated fashion 0ith vivid and colorf.l lan,.a,e< they /ay conf.se te/poral se2.ences and cannot clearly distin,.ish c.rrent fro/ past sy/pto/s- 1e/ale patients 0ith so/ati%ation disorder /ay dress in an e;hi+itionistic /annerPatients /ay +e perceived as dependent selfcentered h.n,ry for ad/iration or praise and /anip.lativeSo/ati%ation disorder is co//only associated 0ith other /ental disorders incl.din, /aAor depressive disorder personality disorders s.+stance-related disorders ,enerali%ed an;iety disorder and pho+iasThe co/+ination of these disorders and the chronic

) '&-year-old fe/ale te/porary clerk presented 0ith chronic and inter/ittent di%%iness paresthesias pain in /.ltiple areas of her +ody and inter/ittent na.sea and diarrhea- *n f.rther history the patient said that the sy/pto/s had +een present /ost of the ti/e altho.,h they had +een .nd.latin, since she 0as appro;i/ately 7& years of a,e- $n addition to the sy/pto/s previo.sly /entioned she had /ild depression 0as disinterested in /any thin,s in life incl.din, se;.al activity and had +een to /any doctors to try to find o.t 0hat 0as 0ron, 0ith her- #ven tho.,h she had seen /any doctors and had /any tests she stated that no one can find o.t 0hat's 0ron, 0ith her- She 0anted another opinionShe co//ented that she had +een sick a lot since childhood and had +een on vario.s /edications on and off- Physical e;a/ination revealed a nor/otensive sli,htly over0ei,ht fe/ale in no ac.te distress- She had diff.se and /ild a+do/inal tenderness 0itho.t tr.e ,.ardin, or re+o.nd tenderness- @er ne.rolo,ical e;a/ination 0as nor/al- She 0inced 0hen physical e;a/ination 0as cond.cted on vario.s parts of her +ody altho.,h this 0incin, 0ent a0ay 0hen the physician 0as speakin, 0ith her 0hile cond.ctin, the

Differential Dia,nosis Ta+le !8-' sho0s the vast differential dia,nosis for so/ati%ation pheno/ena- The three feat.res that /ost s.,,est a dia,nosis of so/ati%ation disorder instead of another /edical disorder are 4!9 the involve/ent of /.ltiple or,an syste/s 479 early onset and chronic co.rse 0itho.t develop/ent of physical si,ns or str.ct.ral a+nor/alities and 4'9 a+sence of la+oratory a+nor/alities that are characteristic of the s.,,ested /edical condition $n the process of dia,nosis the ast.te clinician considers other /edical disorders that are characteri%ed +y va,.e /.ltiple and conf.sin, so/atic sy/pto/s s.ch as thyroid disease hyperparathyroidis/ inter/ittent porphyria /.ltiple sclerosis 43S9 and syste/ic l.p.s erythe/atos.s-

Differential Dia,nosis of the So/ati%in, Patient

Psychophysiolo4ical sy)pto)s @@@Psycholo4ical factors affectin4 physical illness @@@;onpatholo4ical, transient psycho4enic so)atic sy)pto)s 6all are ac(te +(t )ay +eco)e chronic7 @@@=rief and +ereave)ent, 5ith physical sy)pto)s @@@.ear, 5ith physical sy)pto)s @@@E<a44eration or ela+oration of physical sy)pto)s 6e*4*, postaccident, 5hen liti4ation or co)pensation is involved7 @@@Sleep deprivation, 5ith physical sy)pto)s @@@Sensory overload or deprivation, 5ith physical sy)pto)s Psychiatric syndro)es 6other than so)atofor) disorders7 @@@9ood disorders 6e*4*, )a0or depression and

hypochondriasis7 @@@'d0(st)ent disorders 5ith an<iety or depression, or +oth @@@Personality disorders @@@ e)entias So)atofor) disorders @@@So)ati#ation disorder @@@>ypochondriasis @@@Body dys)orphic disorder @@@So)atofor) pain disorder @@@Conversion disorder @@@So)atofor) disorder, not other5ise specified 3ol(ntary psycho4enic sy)pto)s or syndro)es @@@.actitio(s, 5ith physical sy)pto)s 6e*4*, 9(ncha(sen syndro)e7 @@@9alin4erin4, 5ith physical sy)pto)s

Treat/ent So/ati%ation disorder is +est treated 0hen the patient has a sin,le identified physician as pri/ary caretaker- Bhen /ore than one clinician is involved patients have increased opport.nities to e;press so/atic co/plaints- Pri/ary physicians sho.ld see patients d.rin, re,.larly sched.led visits .s.ally at /onthly intervals- The visits sho.ld +e relatively +rief altho.,h a partial physical e;a/ination sho.ld +e cond.cted to respond to each ne0 so/atic co/plaint- )dditional la+oratory and dia,nostic proced.res sho.ld ,enerally +e avoided- *nce so/ati%ation disorder has +een dia,nosed the treatin, physician sho.ld listen to the so/atic co/plaints as e/otional e;pressions rather than as /edical co/plaints- >evertheless patients 0ith so/ati%ation disorder can also have +ona fide physical illnesses< therefore physicians /.st al0ays .se their A.d,/ent a+o.t 0hat sy/pto/s to 0ork .p and to 0hat e;tent) reasona+le lon,-ran,e strate,y for a pri/ary care physician 0ho is treatin, a patient 0ith so/ati%ation disorder is to increase the patient's a0areness of the possi+ility that psycholo,ical factors are involved in the sy/pto/s .ntil the patient is 0illin, to see a /ental health clinician- $n co/ple; cases 0ith /any /edical presentations a psychiatrist is +etter a+le to A.d,e 0hether or not to seek a /edical or s.r,ical cons.ltation +eca.se of his or her /edical trainin,< ho0ever a non/edical /ental health professional can e;plore the psycholo,ical antecedents of the disorder as 0ell especially if cons.ltin, closely 0ith a physician-

Psychotherapy +oth individ.al and ,ro.p decreases these patients' personal health care e;pendit.res +y =" percent lar,ely +y decreasin, their rates of hospitali%ation- $n psychotherapy settin,s patients are helped to cope 0ith their sy/pto/s to e;press .nderlyin, e/otions and to develop alternative strate,ies for e;pressin, their feelin,s:ivin, psychotropic /edications 0henever so/ati%ation disorder coe;ists 0ith a /ood or an;iety disorder is al0ays a risk +.t psychophar/acolo,ical treat/ent as 0ell as psychotherape.tic treat/ent of the coe;istin, disorder is indicated- 3edication /.st +e /onitored +eca.se patients 0ith so/ati%ation disorder tend to .se dr.,s erratically and .nrelia+ly- 1e0 availa+le data indicate that phar/acolo,ical treat/ent is effective in patients 0itho.t coe;istin, /ental disorders-

Conversion Disorder

Co))on Sy)pto)s of Conversion isorder 9otor Sy)pto)s $nvol.ntary /ove/ents Tics Blepharospas/ Torticollis *pisthotonos Sei%.res )+nor/al ,ait 1allin, )stasia-a+asia Paralysis Beakness )phonia

Sensory eficits )nesthesia especially of e;tre/ities 3idline anesthesia Blindness T.nnel vision Deafness 3isceral Sy)pto)s Psycho,enic vo/itin, Pse.docyesis :lo+.s hysteric.s S0oonin, or syncope

Conversion disorder is an illness of sy/pto/s or deficits that affect vol.ntary /otor or sensory f.nctions 0hich s.,,est another /edical condition +.t that is A.d,ed to +e ca.sed +y psycholo,ical factors +eca.se the illness is preceded +y conflicts or other stressors- The sy/pto/s or deficits of conversion disorder are not intentionally prod.ced are not ca.sed +y s.+stance .se are not li/ited to pain or se;.al sy/pto/s and the ,ain is pri/arily psycholo,ical and not social /onetary or le,al 4Ta+le !8-&9The syndro/e c.rrently kno0n as conversion disorder 0as ori,inally co/+ined 0ith the syndro/e kno0n as so/ati%ation disorder and 0as referred to as hysteria conversion reaction or dissociative reaction- Pa.l Bri2.et and ?ean3artin Charcot contri+.ted to the develop/ent of the concept of conversion disorder +y notin, the infl.ence of heredity on the sy/pto/ and the co//on association 0ith a tra./atic event- The ter/ conversion 0as introd.ced +y Si,/.nd 1re.d 0ho +ased on his 0ork 0ith )nna *

Epide)iolo4y So)e sy)pto)s of conversion disorder that are not s(fficiently severe to 5arrant the dia4nosis )ay occ(r in (p to one third of the 4eneral pop(lation so)eti)e d(rin4 their lives* :eported rates of conversion disorder vary fro) 11 of 100,000 to %00 of 100,000 in 4eneral pop(lation sa)ples* ')on4 specific pop(lations, the occ(rrence of conversion disorder )ay +e even hi4her than that, perhaps )akin4 conversion disorder the )ost co))on so)atofor) disorder in so)e pop(lations* Several st(dies have reported that F to 1F percent of psychiatric cons(ltations in a 4eneral hospital and -F to %0 percent of ad)issions to a 3eterans 'd)inistration hospital involve patients 5ith conversion disorder dia4noses* "he ratio of 5o)en to )en a)on4 ad(lt patients is at least - to 1 and as )(ch as 10 to 1E a)on4 children, an even hi4her predo)inance is seen in 4irls* Sy)pto)s are )ore co))on on the left than on the ri4ht side of the +ody in 5o)en* Co)en 5ho present 5ith conversion sy)pto)s are )ore likely s(+se8(ently to develop so)ati#ation disorder than 5o)en 5ho have not had conversion sy)pto)s* 'n association e<ists +et5een conversion disorder and antisocial personality disorder in )en* 9en 5ith conversion disorder have often +een involved in occ(pational or )ilitary accidents* "he onset of conversion disorder is 4enerally fro) late childhood to early ad(lthood and is rare +efore 10 years of a4e or after %F years of a4e, +(t onset as late as the ninth decade of life has +een reported* Chen sy)pto)s s(44est a conversion disorder onset in )iddle or old a4e, the pro+a+ility of an occ(lt ne(rolo4ical or other )edical condition is hi4h* Conversion sy)pto)s in children yo(n4er than 10 years of a4e

#tiolo,y Psychoanalytic 1actors )ccordin, to psychoanalytic theory conversion disorder is ca.sed +y repression of .nconscio.s intrapsychic conflict and conversion of an;iety into a physical sy/pto/- The conflict is +et0een an instinct.al i/p.lse 4e-,a,,ression or se;.ality9 and the prohi+itions a,ainst its e;pression- The sy/pto/s allo0 partial e;pression of the for+idden 0ish or .r,e +.t dis,.ise it so that patients can avoid conscio.sly confrontin, their .naccepta+le i/p.lses< that is the conversion disorder sy/pto/ has a sy/+olic relation to the .nconscio.s conflictQRUfor e;a/ple va,inis/.s protects the patient fro/ e;pressin, .naccepta+le se;.al 0ishes- Conversion disorder sy/pto/s also allo0 patients to co//.nicate that they need special

Dearnin, Theory $n ter/s of conditioned learnin, theory a conversion sy/pto/ can +e seen as a piece of classically conditioned learned +ehavior< sy/pto/s of illness learned in childhood are called forth as a /eans of copin, 0ith an other0ise i/possi+le sit.ation Biolo,ical 1actors $ncreasin, data i/plicate +iolo,ical and ne.ropsycholo,ical factors in the develop/ent of conversion disorder sy/pto/s- Preli/inary +raini/a,in, st.dies have fo.nd hypo/eta+olis/ of the do/inant he/isphere and hyper/eta+olis/ of the nondo/inant he/isphere and have i/plicated i/paired he/ispheric co//.nication in the ca.se of conversion disorder- The sy/pto/s /ay +e ca.sed +y an e;cessive cortical aro.sal that sets off ne,ative feed+ack loops +et0een the cere+ral corte; and the +rainste/ retic.lar for/ation- #levated levels of corticof.,al o.tp.t in t.rn inhi+it the patient's a0areness of +odily sensation 0hich /ay e;plain the o+served sensory deficits in so/e patients 0ith

S9,!3,": isorder

ia4nostic Criteria for Conversion

*ne or /ore sy/pto/s or deficits affectin, vol.ntary /otor or sensory f.nction that s.,,est a ne.rolo,ical or other ,eneral /edical conditionPsycholo,ical factors are A.d,ed to +e associated 0ith the sy/pto/ or deficit +eca.se the initiation or e;acer+ation of the sy/pto/ or deficit is preceded +y conflicts or other stressorsThe sy/pto/ or deficit is not intentionally prod.ced or fei,ned 4as in factitio.s disorder or /alin,erin,9The sy/pto/ or deficit cannot after appropriate investi,ation +e f.lly e;plained +y a ,eneral /edical condition or +y the direct effects of a s.+stance or as a c.lt.rally sanctioned +ehavior or e;perience-

The sy/pto/ or deficit ca.ses clinically si,nificant distress or i/pair/ent in social occ.pational or other i/portant areas of f.nctionin, or 0arrants /edical eval.ationThe sy/pto/ or deficit is not li/ited to pain or se;.al dysf.nction does not occ.r e;cl.sively d.rin, the co.rse of so/ati%ation disorder and is not +etter acco.nted for +y another /ental disorderSpecify type of sy/pto/ or deficit: KKKCith )otor sy)pto) or deficit KKKCith sensory sy)pto) or deficit KKKCith sei#(res or conv(lsions KKKCith )i<ed presentation

Dia,nosis The DS3-$J-TR li/its the dia,nosis of conversion disorder to those sy/pto/s that affect a vol.ntary /otor or sensory f.nction that is ne.rolo,ical sy/pto/s 4Ta+le !8-=9- Physicians cannot e;plain the ne.rolo,ical sy/pto/s solely on the +asis of any kno0n ne.rolo,ical conditionThe dia,nosis of conversion disorder re2.ires that clinicians find a necessary and critical association +et0een the ca.se of the ne.rolo,ical sy/pto/s and psycholo,ical factors altho.,h the sy/pto/s cannot res.lt fro/ /alin,erin, or factitio.s disorder- The dia,nosis of conversion disorder also e;cl.des sy/pto/s of pain and se;.al dysf.nction and sy/pto/s that occ.r only in so/ati%ation disorder- DS3-$J-TR allo0s specification of the type of sy/pto/ or deficit seen in conversion disorder

Clinical 1eat.res Paralysis +lindness and /.tis/ are the /ost co//on conversion disorder sy/pto/sConversion disorder /ay +e /ost co//only associated 0ith passive-a,,ressive dependent antisocial and histrionic personality disordersDepressive and an;iety disorder sy/pto/s often acco/pany the sy/pto/s of conversion disorder and affected patients are at risk for s.icide-

3r- ? is a 75-year-old sin,le /an 0ho is e/ployed in a factory- @e 0as +ro.,ht to an e/er,ency depart/ent +y his father co/plainin, that he had lost his vision 0hile sittin, in the +ack seat on the 0ay ho/e fro/ a fa/ily ,atherin,- @e had +een playin, volley+all at the ,atherin, +.t had s.stained no si,nificant inA.ry e;cept for the volley+all hittin, hi/ in the head a fe0 ti/es- )s 0as .s.al for this /an he had +een rel.ctant to play volley+all +eca.se of the lack of his athletic skills and 0as placed on a tea/ at the last /o/ent- @e recalls havin, so/e pro+le/s 0ith seein, d.rin, the ,a/e +.t his vision did not +eco/e a+lated .ntil he 0as in the car on the 0ay ho/e- By the ti/e he ,ot to the e/er,ency depart/ent his vision 0as i/provin, altho.,h he still co/plained of +l.rriness and /ild diplopia- The do.+le vision co.ld +e atten.ated +y havin, hi/ foc.s on ite/s at different distances*n e;a/ination 3r- ? 0as f.lly cooperative so/e0hat .ncertain a+o.t 0hy this 0o.ld have occ.rred and rather nonchalant- P.pillary oc.lo/otor and ,eneral sensori/otor e;a/inations 0ere nor/al- )fter +ein, cleared /edically the patient 0as sent to a /ental

)t the /ental health center the patient reco.nts the sa/e story as he did in the e/er,ency depart/ent and he 0as still acco/panied +y his father- @e +e,an to reco.nt ho0 his vision started to ret.rn to nor/al 0hen his father p.lled over on the side of the road and +e,an to talk to hi/ a+o.t the events of the day- @e spoke 0ith his father a+o.t ho0 he had felt e/+arrassed and so/e0hat conflicted a+o.t playin, volley+all and ho0 he had felt that he really sho.ld play +eca.se of e;ternal press.res- 1.rther history fro/ the patient and his father revealed that this yo.n, /an had +een shy as an adolescent partic.larly aro.nd athletic participation- @e had never had another episode of vis.al loss- @e did reco.nt feelin, an;io.s and so/eti/es not feelin, 0ell in his +ody d.rin, athletic activitiesDisc.ssion 0ith the patient at the /ental health center foc.sed on the potential role of psycholo,ical and social factors in ac.te vision loss- The patient 0as so/e0hat perple;ed +y this +.t 0as also a/ena+le to disc.ssion- @e stated that he clearly reco,ni%ed that he +e,an seein, and feelin, +etter 0hen his father p.lled off to the side of the road and disc.ssed thin,s 0ith hi/- Doctors ad/itted that they did not kno0 the ca.se of the vision loss and that it 0o.ld likely not ret.rn- The patient and his father 0ere satisfied 0ith the /edical and psychiatric eval.ation and a,reed to ret.rn for care if there 0ere any f.rther sy/pto/s- The patient 0as appointed a follo0-.p ti/e at the o.tpatient psychiatric clinic- 4Co.rtesy of 3ichael )-

Sensory Sy/pto/s $n conversion disorder anesthesia and paresthesia are co//on especially of the e;tre/ities- )ll sensory /odalities can +e involved and the distri+.tion of the dist.r+ance is .s.ally inconsistent 0ith either central or peripheral ne.rolo,ical disease- Th.s clinicians /ay see the characteristic stockin,-and-,love anesthesia of the hands or feet or the he/ianesthesia of the +ody +e,innin, precisely alon, the /idlineConversion disorder sy/pto/s /ay involve the or,ans of special sense and can prod.ce deafness +lindness and t.nnel vision- These sy/pto/s can +e .nilateral or +ilateral +.t ne.rolo,ical eval.ation reveals intact sensory path0ays- $n conversion disorder +lindness for e;a/ple patients 0alk aro.nd 0itho.t collisions or selfinA.ry their p.pils react to li,ht and their cortical evoked potentials are nor/al-

3otor Sy/pto/s The /otor sy/pto/s of conversion disorder incl.de a+nor/al /ove/ents ,ait dist.r+ance 0eakness and paralysis- :ross rhyth/ical tre/ors choreifor/ /ove/ents tics and Aerks /ay +e present- The /ove/ents ,enerally 0orsen 0hen attention is called to the/- *ne ,ait dist.r+ance seen in conversion disorder is astasia-a+asia 0hich is a 0ildly ata;ic sta,,erin, ,ait acco/panied +y ,ross irre,.lar Aerky tr.ncal /ove/ents and thrashin, and 0avin, ar/ /ove/ents- Patients 0ith the sy/pto/s rarely fall< if they do they are ,enerally not inA.red*ther co//on /otor dist.r+ances are paralysis and paresis involvin, one t0o or all fo.r li/+s altho.,h the distri+.tion of the involved /.scles does not confor/ to the ne.ral path0aysRefle;es re/ain nor/al< the patients have no fascic.lations or /.scle atrophy 4e;cept after lon,-standin, conversion paralysis9<

Sei%.re Sy/pto/s Pse.dosei%.res are another sy/pto/ in conversion disorder- Clinicians /ay find it diffic.lt to differentiate a pse.dosei%.re fro/ an act.al sei%.re +y clinical o+servation alone- 3oreover a+o.t one third of the patient's pse.dosei%.res also have a coe;istin, epileptic disorder- Ton,.e-+itin, .rinary incontinence and inA.ries after fallin, can occ.r in pse.dosei%.res altho.,h these sy/pto/s are ,enerally not presentP.pillary and ,a, refle;es are retained after pse.dosei%.re and patients have no postsei%.re increase in prolactin concentrations *ther )ssociated 1eat.res Several psycholo,ical sy/pto/s have also +een associated 0ith conversion disorder Pri/ary :ain Patients achieve pri/ary ,ain +y keepin, internal conflicts o.tside their a0areness- Sy/pto/s have

Secondary :ain Patients accr.e tan,i+le advanta,es and +enefits as a res.lt of +ein, sick< for e;a/ple +ein, e;c.sed fro/ o+li,ations and diffic.lt life sit.ations receivin, s.pport and assistance that /i,ht not other0ise +e forthco/in, and controllin, other persons' +ehavior Da Belle $ndiffOrence Da +elle indiffOrence is a patient's inappropriately cavalier attit.de to0ard serio.s sy/pto/s< that is the patient see/s to +e .nconcerned a+o.t 0hat appears to +e a /aAor i/pair/ent- That +land indifference is also seen in so/e serio.sly ill /edical patients 0ho develop a stoic attit.de- The presence or a+sence of la +elle indiffOXrence is not pathno,no/onic of conversion disorder +.t it is often associated 0ith the condition $dentification Patients 0ith conversion disorder /ay .nconscio.sly /odel their sy/pto/s on those of so/eone i/portant to the/- 1or e;a/ple a parent or a person 0ho has recently died /ay serve as a /odel for conversion disorder- D.rin, patholo,ical ,rief reaction +ereaved persons co//only have sy/pto/s of the deceased

Differential Dia,nosis *ne of the /aAor pro+le/s in dia,nosin, conversion disorder is the diffic.lty of definitively r.lin, o.t a /edical disorder- Conco/itant nonpsychiatric /edical disorders are co//on in hospitali%ed patients 0ith conversion disorder and evidence of a c.rrent or previo.s ne.rolo,ical disorder or a syste/ic disease affectin, the +rain has +een reported in !5 to (& percent of s.ch patients- )n esti/ated 7= to =" percent of patients classified as havin, conversion disorder event.ally receive dia,noses of ne.rolo,ical or nonpsychiatric /edical disorders that co.ld have ca.sed their earlier sy/pto/s- Th.s a thoro.,h /edical and ne.rolo,ical 0ork.p is essential in all cases- $f the sy/pto/s can +e resolved +y s.,,estion hypnosis or parenteral a/o+ar+ital 4)/ytal9 or lora%epa/ 4)tivan9 they are pro+a+ly the res.lt

>e.rolo,ical disorders 4e-,- de/entia and other de,enerative diseases9 +rain t./ors and +asal ,an,lia disease /.st +e considered in the differential dia,nosis- 1or e;a/ple 0eakness /ay +e conf.sed 0ith /yasthenia ,ravis poly/yositis ac2.ired /yopathies or 3S- *ptic ne.ritis /ay +e /isdia,nosed as conversion disorder +lindness- *ther diseases that can ca.se conf.sin, sy/pto/s are :.illain-BarrOX syndro/e Cre.t%feldt-?ako+ disease periodic paralysis and early ne.rolo,ical /anifestations of ac2.ired i//.nodeficiency syndro/e 4)$DS9- Conversion disorder sy/pto/s occ.r in schi%ophrenia depressive disorders and an;iety disorders +.t these other disorders are associated 0ith their o0n

Sensori/otor sy/pto/s also occ.r in so/ati%ation disorder- B.t so/ati%ation disorder is a chronic illness that +e,ins early in life and incl.des sy/pto/s in /any other or,an syste/s$n hypochondriasis patients have no act.al loss or distortion of f.nction< the so/atic co/plaints are chronic and are not li/ited to ne.rolo,ical sy/pto/s and the characteristic hypochondriacal attit.des and +eliefs are present- $f the patient's sy/pto/s are li/ited to pain pain disorder can +e dia,nosed- Patients 0hose co/plaints are li/ited to se;.al f.nction are classified as havin, a se;.al dysf.nction rather than conversion disorder$n +oth /alin,erin, and factitio.s disorder the sy/pto/s are .nder conscio.s vol.ntary control) /alin,erer's history is .s.ally /ore inconsistent and contradictory than that of a patient 0ith conversion disorder and a /alin,erer's fra.d.lent +ehavior is clearly ,oal directed-

Co.rse and Pro,nosis The onset of conversion disorder is .s.ally ac.te +.t a crescendo of sy/pto/atolo,y /ay also occ.r- Sy/pto/s or deficits are .s.ally of short d.ration and appro;i/ately 6= percent of ac.te cases re/it spontaneo.sly .s.ally 0ithin 7 0eeks in hospitali%ed patients- $f sy/pto/s have +een present for ( /onths or lon,er the pro,nosis for sy/pto/ resol.tion is less than =" percent and di/inishes f.rther the lon,er that conversion is present- Rec.rrence occ.rs in one fifth to one fo.rth of people 0ithin ! year of the first episode- Th.s one episode is a predictor for f.t.re episodes- ) ,ood pro,nosis is heralded +y ac.te onset presence of clearly identifia+le stressors at the ti/e of onset a short interval +et0een onset and the instit.tion of treat/ent and a+ove avera,e intelli,ence- Paralysis aphonia and +lindness are associated 0ith a ,ood pro,nosis 0hereas tre/or and sei%.res are poor pro,nostic factors-

Treat/ent Resol.tion of the conversion disorder sy/pto/ is .s.ally spontaneo.s altho.,h it is pro+a+ly facilitated +y insi,htoriented s.pportive or +ehavior therapy- The /ost i/portant feat.re of the therapy is a relationship 0ith a carin, and confident therapist- Bith patients 0ho are resistant to the idea of psychotherapy physicians can s.,,est that the psychotherapy 0ill foc.s on iss.es of stress and copin,- Tellin, s.ch patients that their sy/pto/s are i/a,inary often /akes the/ 0orse- @ypnosis an;iolytics and +ehavioral rela;ation e;ercises are effective in so/e cases- Parenteral a/o+ar+ital or lora%epa/ /ay +e helpf.l P-(&7 in o+tainin, additional historic infor/ation especially 0hen a patient has recently e;perienced a tra./atic eventPsychodyna/ic approaches incl.de psychoanalysis and insi,htoriented psychotherapy in 0hich patients e;plore intrapsychic conflicts and the sy/+olis/ of the conversion disorder sy/pto/s- Brief and direct for/s of short-ter/ psychotherapy have also +een .sed to treat conversion disorder- The lon,er the d.ration of these patients' sick role and the /ore they have re,ressed the /ore diffic.lt the treat/ent-

1.nctional and Behavioral >e.roanato/y Sadock BenAa/in ?a/es< Sadock Jir,inia )lcott Title: Kaplan & Sadock's Synopsis of Psychiatry

#D$T DR D$G)

1.n,si otak
neocorte;

+erfikir +erhit.n, /e/ori +ahasa sistek li/+ic +erf.,si dala/ /en,at.r e/osi dan /e/ori e/osional +atan, otak /en,ar.r f.n,si ve,etasi t.+.h antara lain deny.t Aant.n, aliran darah ke/a/p.an ,erak ata. /otorik

K!:! '"'S 1o4is K(antitatif Kritis 'nalitis .act(al

Ko4nitif Pra4)ati k

Kanan atas
Konsept(al Sintesis 9etaforis 3is(al !nte4rative

Chole Brained

:ealistis Co))on Sense

Kreatif ;at(ral

!dealistis Kinestetik

Sek(ensial "erkontrol Konservatif Str(kt(ral 9endetail

E)osional !ndria5i >()anistik 9(sical Ekspresif !nt(itif !nstin4tif Kanan +a5ah

Kiri +a5ah

)nato/i otak

:e4ional .(nctions of the >()an Brain

1rontal lo+es KKKJol.ntary /ove/ent KKKDan,.a,e prod.ction 4left9 KKK3otor prosody 4ri,ht9 KKKCo/port/ent KKK#;ec.tive f.nction KKK3otivation Te/poral lo+es KKK).dition KKKDan,.a,e co/prehension 4left9 KKKSensory prosody 4ri,ht9 KKK3e/ory KKK#/otion

Parietal lo+es KKKTactile sensation KKKJis.ospatial f.nction 4ri,ht9 KKKReadin, 4left9 KKKCalc.lation 4left9 *ccipital lo+es KKKJision KKKJis.al perception 4Reprinted fro/ 1illey C3Neurobehavioral Anatomy>i0ot C*: Eniversity Press of Colorado< !66=:( 0ith per/ission-9

=-@T!) action< partial a,onist< an;iolytic =-@T!B Possi+le role in loco/otor activity a,,ression =-@T!D Tar,et of anti/i,raine dr., s./atriptan =-@T!1 Tar,et of anti/i,raine dr., s./atriptan =-@T( )C Tar,et of hall.cino,ens atypical antipsychotics

3onoa/ine Receptors: S#R*T*>$> =-@T7) P$ t.rnover )ntidepressant

Tar,et of hall.cino,ens atypical antipsychotics =-@T7B P$ t.rnoverRe,.lation of sto/ach contraction =-@T7C P$ t.rnoverRe,.lation of appetite an;iety sei%.res< tar,et of hall.cino,ens antipsychotics =-@T' Cation selective $on channel)nta,onists antie/etic an;iolytic co,nitive enhance/ent =-@T )C 3od.lation of

 @ista/ine @!

P$ t.rnover )nta,onists prod.ce sedation 0ei,ht ,ain @7 )C )nta,onists for peptic .lcer disease @' Enkno0n )nta,onists prod.ce aro.sal appetite

Dopa/ine D! )C D! and D7 receptor sti/.lation syner,istic< re2.ired for sti/.lant effects of cocaine D7 )C Tar,et of therape.tic and e;trapyra/idal effects of dopa/ine receptor anta,onists 4typical antipsychotics9 D' )C Enkno0n D& )C Tar,et of serotonin-dopa/ine anta,onists 4atypical antipsychotic9 D= )C Enkno0n

 )drener,ic

) B D P$ t.rnover )nta,onists antihypertensive 7 ) B C )C ),onists sedative and antihypertensive ! )C Re,.lation of cardiac f.nction 7 )C Re,.lation of +ronchial /.scle contraction ' )C Re,.lation of adipose tiss.e f.n

Choliner,ic 3! P$ t.rnover Re,.lation of co,nition sei%.res 37 )C Re,.lation of cardiac f.nction 3' P$ t.rnover Re,.lation of s/ooth /.scle contraction 3& )C Tar,et of antiparkinsonian anticholiner,ic dr.,s 3= P$ t.rnover Enkno0n >)ChRCation selective $on channelRe,.lation of to+acco .se sei%.res< possi+le co,nitive enhance/ent

Serotonin and Dr.,s So/e of the ne0 relations +et0een serotonin and dr.,s .nder develop/ent are disc.ssed a+ove< ho0ever the historical association of serotonin and psychotropic dr.,s 0as first /ade 0ith the tricyclic dr.,s and the 3)*$s as descri+ed for norepinephrine and epinephrine The tricyclic dr.,s and the 3)*$s respectively +lock the .ptake and the /eta+olis/ of serotonin and norepinephrine th.s increasin, the concentration of +oth ne.rotrans/itters in the synaptic cleft 1l.o;etine is one of the selective serotonin re.ptake inhi+itors 4SSR$s9 that are .sed in the treat/ent of depression- *ther dr.,s in that class incl.de paro;etine 4Pa;il9 sertraline 4Goloft9 fl.vo;a/ine 4D.vo;9 and citalopra/ 4Cele;a9 all of 0hich are .s.ally associated 0ith /ini/al adverse effects especially in

Jenlafa;ine +locks the re.ptake of +oth serotonin and norepinephrine- Bith respect to serotonin +oth tra%odone 4Desyrel9 and nefa%odone +lock the re.ptake of serotonin and directly anta,oni%e =-@T7 receptors 0ith the net effect sti/.latin, =-@T! receptorsTra%odone and nefa%odone and the =-@T! receptor a,onist +.spirone are the first of 0hat 0ill likely +e a series of dr.,s that tar,et s.+types of serotonin receptors)nother serotoner,ic dr., that has +een .sed in psychiatry is D-tryptophan- Beca.se the concentration of D-tryptophan is the rate-li/itin, f.nction in the synthesis of serotonin in,estion of D-tryptophan can increase the concentration of serotonin in the C>S- Dtryptophan 0as 0ithdra0n fro/ the /arket in !66" in the Enited States +y the 1ood and Dr., )d/inistration 41D)9 +eca.se a conta/inant fro/ the prod.ction process at one partic.lar /an.fact.rin, site ca.sed an eosinophilia-/yal,ia syndro/e in so/e patients takin, the dr.,- Recent data s.,,est

>e.roche/ical 1indin,s fro/ P#T Radiotracer Scans

Dopa/ineDecreased

.ptake of dopa/ine in striat./ in parkinsonian patients Dopa/ine release is hi,her in patients 0ith schi%ophrenia than in controls@i,h dopa/ine release associated 0ith positive sy/pto/s in schi%ophrenia-

 Receptors D!

receptor Do0er D! receptor +indin, in prefrontal corte; of patients 0ith schi%ophrenia co/pared 0ith controls< correlates 0ith ne,ative sy/pto/s D7 receptor Schi%ophrenia associated 0ith s/all elevations of +indin, at D7 receptor Serotonin Type !) 4=-@T!)9 Red.ction in receptor

Transporters Dopa/ine )/pheta/ine and cocaine ca.se increase in dopa/ineTo.rette's syndro/e sho0s increase in dopa/ine transporter syste/ 4/ay acco.nt for s.ccess of dopa/ine +lockin, therapies9 Serotonin Serotonin +indin, is lo0 in depression alcoholis/ cocainis/ +in,e eatin, and i/p.lse control disorders

3eta+olis/ >icotine Ci,arette s/okin, inhi+its 3)* activity in +rain)/yloid-Deposits Can +e vis.ali%ed in vivo 0ith P#TPhar/acolo,y Plas/a levels of cocaine peak at 7 /inD7 receptor occ.pancy lasts for several 0eeks after discontin.ation of antipsychotic /edicationD7 receptor occ.pancy is lo0er for atypical antipsychotics than typical antipsychotics 4/ay acco.nt for decrease in e;trapyra/idal side effects9-

Ben%odia%epines $ncreased +eta activity Clo%apine 4Clo%aril9 *lan%apine 4Gypre;a9 Risperidone 4Risperdal9 F.etiapine 4Sero2.el9 )ripipra%ole 4)+ilify9 >o si,nificant chan,es Dithi./ Slo0in, or paro;ys/al activity )lcohol Decreased alpha activity< increased theta activity *pioids Decreased alpha activity< increased volta,e of theta and delta 0aves< in overdose slo0 0aves Bar+it.rates$ncreased +eta activity< in 0ithdra0al states ,enerali%ed paro;ys/al activity and spike dischar,es 3ariA.ana$ncreased alpha activity in frontal area of +rain< overall slo0 alpha activity CocaineSi/ilar to /ariA.ana$nhalants Diff.se slo0in, of delta and theta 0aves >icotine $ncreased alpha activity< in 0ithdra0al /arked

#lectroencephalo,ra/ 4##:9 )lterations )ssociated 0ith 3edication and Dr.,s

#lectroencephalo,ra/ 4##:9 )lterations )ssociated 0ith Psychiatric Disorders

Panic disorder Paro;ys/al ##: chan,es consistent 0ith partial sei%.re activity d.rin, attack in one third of patients< focal slo0in, in a+o.t 7=T of patients CatatoniaEs.ally nor/al +.t ##: indicated in ne0 patient presentin, 0ith catatonia to r.le o.t other ca.ses )ttention-deficit/hyperactivity disorder 4)D@D9@i,h prevalence 4.p to ("T9 of ##: a+nor/alities vers.s nor/al controls< spike or spike-0ave dischar,es

 )ntisocial

personality disorder $ncreased incidence of ##: a+nor/alities in those 0ith a,,ressive +ehavior Borderline personality disorde Positive spikes: !&- and ( per second seen in 7=T of patients Chronic alcoholis/ Pro/inent slo0in, and periodic laterali%ed paro;ys/al dischar,es )lcohol 0ithdra0al 3ay +e nor/al in patients 0ho are not delirio.s< e;cessive fast activity in patients 0ith deliri./ De/entia Rarely nor/al in advanced de/entia< /ay +e helpf.l in