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Psychiatry 2003-2004 Edition
Rhoda K Hahn, MD Clinical Professor
DepartmentofPsychiatryand Human Behavior
University of California, Irvine, College of
Lawrence J. Albers, MD Assistant Clinical Professor DepartmentofPsychiatryand Human Behavior University of California, Irvine, College of Medicine Christopher Reist, MD Vice Chairman
DepartmentofPsychiatryand Human Behavior
University of California, Irvine, College of
Current Clinical Strategies Publishing www.ccspublishing.com/ccs
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Copyright ©2003-2004 Current Clinical Strategies Publishing. All rights reserved. This book, or any parts thereof, may not be reproduced, photocopied or stored in an information retrieval network without the permission of the publisher. No warranty for errors or omissions exists, expressed or implied. Readers are advised to consult the drug package insert and other references before using any therapeutic agent. Current Clinical Strategies is a registered trademark of Current Clinical Strategies Publishing. Current Clinical Strategies Publishing 27071 Cabot Road Laguna Hills, California 92653-7011 Phone: 800-331-8227 Internet: www.ccspublishing.com/ccs E-mail: firstname.lastname@example.org Printed in USA ISBN 1-929622-30-9
Assessment and Evaluation
Clinical Evaluation of the Psychiatric Patient
I. Psychiatric History A. Identifying information. Age, sex, marital status, race, referral source. B. Chief complaint (CC). Reason for consultation; the reason is usually a direct quote from the patient. C. History of present illness (HPI) 1. Current symptoms: date of onset, duration and course of symptoms. 2. Previous psychiatric symptoms and treatment. 3. Recent psychosocial stressors: stressful life events that may have contributed to the patient's current presentation. 4. Reason the patient is presenting now. 5. This section provides evidence that supports or rules out relevant diagnoses. Therefore, documenting the absence of pertinentsymptoms is also important. 6. Historical evidence in this section should be relevant to the current presentation. D. Past psychiatric history 1. Previous and current psychiatric diagnoses. 2. History of psychiatric treatment, including outpatient and inpatient treatment. 3. History of psychotropic medication use. 4. History of suicide attempts and potential lethality. E. Past medical history 1. Current and/or previous medical problems. 2. Type oftreatment,includingprescription, over-the-counter medications, home remedies. F. Family history. Relatives with history of psychiatric disorders, suicide or suicide attempts, alcohol or substance abuse. G. Social history 1. Source of income. 2. Level of education, relationship history(including marriages, sexual orientation, number of children); individuals that currently live with patient. 3. Support network. 4. Current alcohol or illicit drug usage. 5. Occupational history. H. Developmental history.Familystructure during childhood, relationships with parental figures and siblings; developmental milestones, peer relationships, school performance.
Agitation or retardation. Circumstantiality. 3. Unusual physical characteristics or movements. angry. 4.characteristics of clothing. Tangentiality. Poverty of speech. euthymic. Echoing of words and phrases. anxious). Repetition of phrases or words in the flow of speech.External range ofexpression. Neologisms. such as answering just “yes or no. Thought processes 1. range and appropriateness. Psychomotor activity. Labile.II. described in terms of quality. Flight of ideas. Full or wide range of affect. A. Minimal responses. f. Generally appropriate. Invention of new words by the patient. The tone.Moderately reduced range of affect. Use of language. Ideas of reference. g. Absence of all or most affect. Bluntedorrestricted. Illogicalshifting between unrelated topics. Definition. 2.levelofhygiene. Sudden cessation of speech. h. Flat. e. 5. Accelerated thoughts that jump from idea to idea. i. dysphoric. often in the middle of a statement. Interpreting . Quality and quantity of speech. typical of mania. Historical information should not be included in this section. d. Clanging. Types of affect a. b.” c. Multiple abrupt changes in affect. 2. Blocking. C. D. 2. Pressured speech. General appearance and behavior 1. The mental status exam is an assessment of the patient at the present time. Loosening of associations. l. Common thought disorders a. Perseveration.Unnecessary digression. euphoric. j. Speech based on sound. Attitude. Affect 1. k. which eventually reaches the point. b. Thought that wanders from the original point. Degree of eye contact. associations and fluencyof speech should be noted. Mental Status Exam. Internal emotional tone of the patient (ie. such as rhyming and punning rather than logical connections. Ability to interact with the interviewer. B. which is typical of patients with manic disorder. d. c. Mood. Echolalia. Grooming. Rapid speech.
False belief that others are trying to cause harm. visual. Subtraction of serial 7s.tactile. Hallucinations. iii. Insight. i. Ability to make sound . Persecutory delusions. Short-term memory: Ability to recall three objectsafterfive minutes. Attention and concentration: Repeat five digits forwards and backwards or spell a five-letter word(“world”) forwards and backwards. such as believing thatthe television is talking specifically to them. Illusions. false beliefs.delusions and other perceptual disturbances. or historical dates. Misinterpretations of reality. Suicidal and homicidal ideation requires further elaboration with comments about intent and planning (including means to carry out plan). False belief that a person. Cognitive evaluation 1. Thought content 1. which may be auditory. Fund of knowledge: Ability to name past five presidents. G. False sensory perceptions. Common thought content disorders a. or wealth. c. d. power. e. usually of higher status. 5. Orientation: Person. Calculations. f. Erotomanic delusions. 7. Grandiose delusions. Delusions. place and date. Hallucinations. Feelings of unrealness. Feelings of unrealness involving the outer environment. simple math problems. is in love with the patient. 6. Somatic delusions. unrelated events as having direct reference to the patient. b. H. Abstraction. 2. Derealization. knowledge. False belief that the patient has aphysical disorder or defect. five large cities. and the ability to understand the implication of these problems. 2. F.E. gustatory or olfactory. firmlyheldinspite of contradictory evidence. ii. Proverb interpretation and similarities. Judgment. Depersonalization. Fixed. Suicidaland homicidal ideation. 3. False belief of an inflated sense of self-worth. Definition. Level of consciousness. 4. iv. such as if one is “outside” of the body and observing his own activities. Ability of the patient to display an understandingofhiscurrentproblems. or are spying with intent to cause harm.
This section should discuss pharmacologic treatment and otherpsychiatric therapy. thyroid function. 8. Screening test for syphilis (RPR or MHA-TP). CBC with differential. A. V. should be completed. Blood alcohol level. Axis II: Personality disorders Mental retardation Axis III: General medical conditions Axis IV: Psychosocial and environmental problems Axis V: Global assessment of functioning IV. such as Tylenol. B. 3. A thorough physical and neurological examination. elopement precautions.ratherthan byasking hypothetical questions. HIV test in high-risk patients. Admitting Orders Admit to: (name of unit) Diagnosis: DSM-IV diagnosis justifying the admit. Legal Status: Voluntary or involuntary status-if involuntary. state specific status. Precautions: Assault or suicide precautions. Labs: Chem 20.decisions regarding everydayactivities. General Medical Screening of the Psychiatric Patient. ADA diet. soft mechanical. then q day if stable. Judgement is best evaluated by assessing a patient's historyof decision making. Medications: As indicated by the patient’s diagnosis or target symptoms. 6. 4. urine pregnancy test. Amore extensive workup and laboratory studies may be indicated based on clinical findings. Serum levels of medications. vitals should be ordered more frequently. Treatment Plan. UA with toxicology screen. 9. 5. Include as needed medications. Urinalysis with drug screen. 2.including hospitalization. . Urine pregnancycheck for females of child bearing potential. Laboratoryevaluationof the psychiatric patient 1. if there are medical concerns. CBC with diff. Blood chemistry (SMAC). III. including basic screening laboratory studies to rule out physical conditions. Vitals: Standard orders are q shift x 3. Diet: Regular diet. RPR. 7. Thyroid function panel. Condition: Stable. Allergies: No known allergies. serum levels of medications. Activity: Restrict to the unit or allow patient to leave unit. DSM-IVMultiaxialAssessment Diagnosis Axis I: Clinical disorders Other conditions that may be a focus of clinical attention.
then 4 mg po qhs. . Bipolar I Disorder Admitting Orders Admit to: Acute Psychiatric Unit. RPR. urine pregnancy test. Milk of magnesia 30 cc po q 12 hours prn constipation. Condition: Actively Psychotic. 5150 in California). Tylenol 650 mg po q 4 hours prn pain or fever. UA with toxicology screen. valproate level. RPR. thyroid function. thyroid function. Lorazepam (Ativan) 2 mg po q 4 hours prn agitation (not to exceed 8 mg/24 hours. antacids. then q day if stable. urine pregnancy test. CBC with diff. Activity: Restrict to unit. Diet: Regular. Precautions: Elopement precautions. Medications: Risperidone (Risperdal) 2 mg po bid x 2 days. Medications: Olanzapine (Zyprexa) 10 mg po qhs. Labs: Chem 20. CBC with diff. Allergies: No known allergies. Diagnosis: Schizophrenia. Allergies: No known allergies. Activity: Restrict to unit. Diet: Regular. Legal Status: Involuntary by conservator. Diagnosis: Bipolar I Disorder. Milk of magnesia 30 cc po q 12 hours prn constipation. Zolpidem (Ambien) 10 mg po qhs prn insomnia. then q day if stable. Depakote 500 mg po tid. Zaleplon (Sonata) 10 mg po qhs prn insomnia. Condition: Actively Psychotic. Tylenol 650 mg po q 4 hours prn pain or fever. Mylanta 30 cc po q 4 hours prn dyspepsia. Acute Exacerbation. Schizophrenia Admitting Orders Admit to: Acute Psychiatric Unit.milk of magnesia. UA with toxicology screen. Mylanta 30 cc po q 4 hours prn dyspepsia. Legal Status: Involuntary (legal hold. Manic with psychotic features. Lorazepam (Ativan) 2 mg po q 4 hours prn agitation (not to exceed 8 mg/24 hours. Continuous Paranoid Type. Vitals: q shift x 3. Precautions: Assault precautions. Vitals: q shift x 3. Labs: Chem 20.
Diet: Regular. Milk of magnesia 30 cc po q 12 hours prn constipation. Tylenol 650 mg po q 4 hours prn pain or fever. Allergies: No known allergies. Legal Status: Voluntary. then q day if stable. Mylanta 30 cc po q 4 hours prn dyspepsia. Thiamine 100 mg IM qd x 3 days. Diagnosis: Major Depression. Legal Status: Voluntary. Medications: Sertraline (Zoloft) 50 mg po qAM. without psychotic features. then discontinue. severe. CBC with diff. then q day if stable. urine pregnancy test. Allergies: No known allergies. Multivitamin 1 po qd. then 2 mg bid x 2 days. Condition: Guarded. thyroid function. RPR. diastolic BP >100 [not to exceed 14 mg/24 hour]). Activity: Restrict to unit. thyroid function. UA with toxicology screen. Lorazepam (Ativan) 2 mg po tid x 2 days. CBC with diff. RPR. Zolpidem (Ambien) 10 mg po qhs prn insomnia. Labs: Chem 20. systolic BP >160. Trazodone (Desyrel) 100 mg po qhs prn insomnia. Condition: Stable. Lorazepam (Ativan) 2 mg po q 4 hours prn agitation (not to exceed 8 mg/24 hours. Diagnosis: Alcohol Dependence. then 100 mg po qd. Tylenol 650 mg po q 4 hours prn pain or fever. Labs: Chem 20. urine pregnancy test. Vitals: q shift x 3 days. Milk of magnesia 30 cc po q 12 hours prn constipation. then 1 mg po bid x 2 days. Precautions:Seizure and withdrawal precautions. . Diet: Regular with one can of Ensure with each meal. UA with toxicology screen. Activity: Restrict to unit. Lorazepam (Ativan) 2 mg po q 4 hours prn alcohol withdrawal symptoms (pulse >100. Medications: Folate 1 mg po qd. Precautions: Suicide precautions. Vitals: q shift x 3. Alcohol DependenceAdmitting Orders Admit to: Alcohol Treatment Unit.Major Depression Admitting Orders Admit to: Acute Psychiatric Unit.
Citalopram (Celexa) 20 mg po q am. Condition: Stable. UA with toxicology screen.Mylanta 30 cc po q 4 hours prn dyspepsia. Allergies: No known allergies. Vitals: q shift x 3 days. Schizoaffective Disorder Admitting Orders Admit to: Acute Psychiatric Unit. Precautions: Suicide precautions. Medications: Clonidine (Catapres) 0. Give 0. Zolpidem (Ambien) 10 mg po qhs prn insomnia. Diagnosis: Schizoaffective disorder. Activity: Restrict to unit. hepatitis panel. OpiateDependenceAdmitting Orders Admit to: Acute Psychiatric Unit. Ibuprofen (Advil) 600 mg po q 6 hours prn pain/headache. then q day if stable. Legal Status: Voluntary. depressed. Diet: Regular. Condition: Stable. HIV. hold for systolic BP <90 or diastolic BP <60). RPR. lithium level. Diet: Regular. bipolar type. Precautions: Opiate withdrawal. Diagnosis: Heroin dependance. Lorazepam (Ativan) 2 mg po q 4 hours prn agitation (not to exceed 8 mg/24 hours). Tylenol 650 mg po q 4 hours prn pain . Lithium 600 mg po bid. Labs: Chem 20. Labs: Chem 20. Mylanta 30 cc po q 4 hours prn dyspepsia. Vitals: q shift x 3. Legal Status: Voluntary. Allergies: No known allergies. Dicyclomine (Bentyl) 20 mg po q 6 hours prn cramping. urine pregnancy test.1 mg po qid. Lorazepam (Ativan) 2 mg po q 4 hours prn agitation (not to exceed 8 mg/24 hours. UA with toxicology screen. Activity: Restrict to unit. urine pregnancy test. Zolpidem (Ambien) 10 mg po qhs prn insomnia. then 200 mg po bid.1 mg po q 4 hours prn signs and symptoms ofopiate withdrawal. thyroid function. then q day if stable. Methocarbamol (Robaxin) 500 mg po q 6 hours prn muscle pain. CBC with diff. CBC with diff. Milk of magnesia 30 cc po q 12 hours prn constipation. RPR. thyroid function. Medications: Quetiapine (Seroquel) 100 mg po bid x 2 days.
threat to self. Indication: Confused. Attempting to get our of bed. Agitated. or soft restraints. and arrangements for discharge. 4. or dressing. Restraint Notes The restraint note should document that less restrictive measures were attempted and failed orwereconsidered. 2. plans to treat those problems. threat to self/others. Psychiatric Progress Notes Daily progress notes should summarize the patient’s current clinical condition and should review developments in the patient's hospital course. Staff may decrease or release restraints at their discretion. 4-point leather restraint. Attempting to pull out tube. The note should address problems that remain active. 3. threwa chair and threatened severalpatientsverbally. Restraint Orders 1.or fever. therefore. Mylanta 30 cc po q 4 hours prn dyspepsia. immediate 4-point restraints were required. Type of Restraint: Seclusion. were considered butdeemed inappropriate given his severe agitation and assaultive behavior. threat to self. Monitor patient as directed by hospital policy. He will be given haloperidol (Haldol) 5 mg IM and lorazepam (Ativan) 2 mg IMbecause he has refused oral medication. Milk of magnesia 30 cc po q 12 hours prn constipation. Progress notes should address every element of the problem list. Time Begin at _____o’clock. Example Restraint Note Date/time/writer: The patient became agitated and without provocation. fall risk. line.Hewasunmanageable. Combative. Not to exceed (specify number of hours). Other less restrictive measures. such as locked seclusion.butnotappropriate for the urgent clinical situation. He will be observed per protocol and may be released at staff’s discretion. . 5.
The assessment should include reasons that support the patient’s continuing need for hospitalization. serum drug levels. attention. informed consent issues. Assessment: This section should be organized byproblem. life events. Labs: New test results. Thought Processes: Quality and quantityof speech. paranoid ideation. Current medications:Listmedications and dosages. Thought Content: Hallucinations. Affect: Flat. monitoring of medication side effects (eg. angry. concentration. anxious. associations and fluency of speech. full. Information reported by the patient may include complaints. blunted. suicidal ideation. .stable or activelypsychotic). Tone. Objective: Discuss pertinent clinical events and observations of the nursing staff. Documentation may include suicidality. Plan: Changes to current treatment. euthymic. abnormal involuntary movements). Cognitive: Orientation. future considerations. WBCs. and speech abnormalities.Psychiatric Progress Note Date/time/writer: Subjective: A direct quote from the patient should be written in the chart.Aseparate assessment should be written for each problem (eg. Mood: Dysphoric. symptoms. homicidality. labile.Documentation of dangerousness to self or others should be addressed. and issues that require continued monitoring should be discussed. Insight: Abilityof the patientunderstand his current problems Judgment: Decision-making ability. side effects. euphoric. and feelings.
Con tinue to encourage patient to take medication. Cognitive: The patient would not answer orientation ques tions due to paranoid ideation. The patient remains actively paranoid and intermittently compliant with recom mended medication.Example Inpatient Progress Note Date/time/Psychiatry R2 S: “The FBI is trying to kill me. with extensive impact on functioning. On exam. The patient is actively psychotic and para noid. clothing and shelter for herself. Mood: Dysphoric. Continue to monitor sleep. Risperdal 2 mg PO BID. O: The patient slept for only 2 hours last night and refused to take medications. The patient denies homicidal ideation. Oth erwise the patient remains elec tively mute. She became frightened during our interview and refused to talk after 5 min utes. P: 1. The patient meets criteria for involuntary hospitalization due to an inability to pro vide food. and psychomotor agitation. chronic. Thought Content: Auditory hallucinations and paranoid ideation. 3. Thought Processes: Speech is limited to a few paranoid statements about the FBI. suicidal ideation. . which were offered to her. A: 1. the patient displayed poor eye contact. Affect: Flat. Insight: Poor. Patient also is reluctant to eat or drink fearing that the food is poisoned. Schizophrenia. food and fluid intake. paranoid type with acute exacerbation. Legal Status: The patient is currently hospitalized on an involuntary basis. The patient denies visual hallucination. Draw electrolyte panel in the AM to monitor hydration status. but states that she would harm anyone from the FBI who tried to hurt her.” The patient reports that she was unable to sleep last night because the FBI harassed her by talking to her. 2. Judgment: Impaired.
including evaluation. . mental status exam and physical examination. Discharge Note Date/time: Diagnoses: Treatment: Briefly describe therapy provided during hospitalization. past psychiatric history. CT scan. Axis II: Personality disorders Axis III: Medical conditions Axis IV: Psychosocial and environmental problems Axis V: Global assessment of functioning Attending or Ward Team Responsible for Patient: Surgical Procedures. Diagnostic Data: Results of laboratory testing. Disposition: Describe the situation to which the patient will be discharged (home. and brain imaging. social history.and medical/surgical consultations and treatment. including psychiatric drugtherapy. and the course of treatment. DischargedCondition:Describe improvement or deterioration in the patient's condition. Diagnostic Tests. psychological testing. Invasive Procedures: History of Present Illness: Include salient features surrounding reason for admission. psychological testing. Patient'sNameand MedicalRecordNumber: Date of Admission: Date of Discharge: DSM-IV Multiaxial Discharge Diagnosis Axis I: Clinical disorders Other conditions that maybe a focus of clinical attention.consultations. Hospital Course: Describe the course of the patient's illness while in the hospital. diagnostic tests and response to interventions are also discussed.medications. and describe the present status of the patient.Discharge Note The discharge note should be written in the patient’s chart prior to dis charge. salient psychosocial information. and indicate who will take care of patient. Studies Performed: Electrocardiograms. Discharge Medications: Follow-up Arrangements: Discharge Summary The discharge summary reviews how a patient presented to the hospital. nursing home). outcome of treatment. and unresolved issues at discharge. All items on the problem list should be addressed.
No psychotic symptoms are noted. Psychological Testing Psychological testing often provides additional information that complements the psychiatric history and mental status exam. Example Outpatient Progress Note Subjective: The patient reports improved mood. I. and judgment remains good. dosages. Affect is brighter but still constricted.quantities dispensed. but the patient still has symptoms after 4 weeks of treatment at 200 mg bid. as well asdescribe personalityandmotivations. exercise. sleep. The patient denies any recent suicidal or homicidal ideation. clinic. B. Thinking is logical and goal directed. and is asked to make up a story for each card. but energy remains low. consultants. Refer to senior center for increased social interaction. conflicts. The patient’s spouse reports increased interest in usual activities. Copies: Send copies to attending. fantasies. Continue weekly supportive therapy. conservatorship. Cognition is grossly intact. but output is decreased. particularlyhelpful in psychodynamic formulation and assessment of defensemechanismsandegoboundaries. and interpersonal relationships. and appetite. Discharge Instructions and Follow-up Care: Date of return for follow-up care at clinic. involuntary. Mood remains depressed but improved from the previous visit. Plan: Increase nefazodone from 200 mg bid to 200 mg q AM and 400 mg qhs. defenses.Legal Status at Discharge: Voluntary. Rorschach Test. Speech is more spontaneous.and instructions. Psychological tests characterize psychological symptoms. Objective: The patient is casuallydressed with good grooming. The patient denies any side effects of medications other than mild nausea that has been diminishing over the past few days. Discharge Medications: List medications. . A. The patient is asked to consider pictures of people in a variety of situations. Thematic Apperception Test (TAT). Assessment: Major depressionisimproving with nefazodone (Serzone) and supportive psychotherapy. Ink blots serve as stimuli for free associations. This test provides information about needs. diet. Insight is improving.
A. memory. D. References References. Patients are asked tofinish incomplete sentences.visual-motor function. useful for children and adults. B. see page 121. C. Standardized evaluation of brain functioning. and full-scale IQ. . BenderGestalt Test. D. Halstead-ReitanBatteryandLuria-Nebraska Inventory 1.A test ofvisual-motor and spatial abilities.C. therebyrevealing conscious associations. and the test may also be used as a screening exam for brain damage. Wisconsin Card Sort. E. Sentence Completion Test (SCT). A battery of questions assessing personality characteristics. intellectual reasoning and judgment. Intelligence test that measures verbal IQ. Results are given in 10 scales. The drawings represent how the patient relates to his environment. 2. Neuropsychological tests assess cognitive abilities and can assist in characterizing impaired brain function. The patient is asked to draw a picture of a person. II. Wechsler Adult Intelligence Scale (WAIS). A test of frontal lobe function. Draw-a-Person Test (DAP).performance IQ. Assess expressive and receptive language. fears and preoccupations of the patient. Minnesota Multiphasic Personality Inventory (MMPI). and then to draw a picture of a person of the opposite sex of the first drawing. Provides insight into defenses.sensory-perceptual function and motor function.
d. Delusions. Poverty of speech (alogia) or poverty of thought content. These patients have alterations in thoughts. incoherentthoughts. E. Positive symptoms a. II. If historyof autistic disorder or pervasive developmental disorder is present. c. affective flattening. mood. hallucinations and misinterpretations of reality. c. B. perceptions. b. D. Many schizophrenics display delusions. alogia. Decline in social and/or occupational functioning since the onset of illness.and ideas of reference. Negative symptoms (ie. b. 1. A prior history of schizotypal or schizoid personality traits or disorder is often present. Grossly disorganized or catatonic behavior. and behavior. Continuous signs of illness for at least six months with at least one month of active symptoms. Delusions. I. 2. schizophrenia may be diagnosed onlyifprominentdelusionsorhallucinations have been present for one month. Thought disorder is characterized byloose associations. .thought insertion. Disorganized speech. Depression and neurocognitive dysfunction are gaining acceptance astermsto describe twoothercoresymptoms ofschizophrenia.Psychotic Disorders Schizophrenia Schizophrenia is a disorder characterized by apathy. Clinical Features of Schizophrenia A. and affective blunting. d. DSM-IV Diagnostic Criteria for Schizophrenia A. C. Two or more of the following symptoms present for one month: 1. Hallucinations are mostcommonly auditoryor visual. 4. avolition). Loss of motivation (avolition). thoughtblocking. B. 2.buthallucinations can occurinanysensorymodality. absence of initiative (avolition). 5. Flat affect. tangentiality. Anhedonia.neologisms. 3. The disturbance is not due to substance abuse or a medical condition F. Symptoms of schizophrenia have been traditionally categorized as either positive or negative. Negative symptoms a. Schizoaffective disorder and mood disorder with psychotic features have been excluded. Hallucinations. thought broadcasting. Disorganized behavior.
The lifetime prevalence of schizophrenia is one percent. similar to the rate that occurs in depressive illnesses. disorganized or catatonic behavior. disorganized behavior. Atypical antipsychotics mayimprove cognitive impairment. E. Loss of social interest.e. No sign or symptom is pathognomonic of schizophrenia. C. and the incidence of substance abuse is increased (especially alcohol. 4. Depression is common and often severe in schizophrenia and can compromise functional status and response to treatment. but the mean age ofonsetisapproximately six years later in females. Sensorium is intact. Onset of psychosis usually occurs in the late teens or early twenties. B. C. III. Excessive motor activity. olfactory or gustatoryhallucinations mayindicate an organic etiology such as complex partial seizures. D. Cognitive dysfunction (including attention. Males and females are equallyaffected. 3. The suicide rate is 10-13%. executive function. . D. 2. and flat or inappropriate affect. More than 75% of patients are smokers. Most patients followa chronic downward course. C. Females frequently have a milder course of illness. Motoric immobility. Catatonic type Schizophrenia is characterized by at least two of the following: 1. 2. or flat or inappropriate affect. E. f. Epidemiology of Schizophrenia A.butantidepressants may be required. IV. Paranoid type schizophrenia is characterized by the absence of prominentdisorganization ofspeech. Paranoid type Schizophrenia 1. B. Insight and judgment are frequently impaired. F. Attentional deficits. The presence of tactile. Atypical antipsychotics often improve depressive signs and symptoms. Disorganized type Schizophrenia is characterized byprominentdisorganized speech. Cognitive impairment.Classification of Schizophrenia A. cocaine. and particular types of memory) contribute to disability and can be an obstacle in long-term treatment. Characterized by a preoccupation with one or more delusions or frequent auditory hallucinations. Very few patients have a complete recovery. methamphetamine and marijuana). but some have a gradual improvement with a decrease in positive symptoms and increased functioning.
thyrotoxicosis. the duration of mood symptoms is brief compared to the entire duration of the illness. Pharmacotherapy. Schizotypal. Delusional disorder. Schizoaffective disorder. delirium. C. schizoid or borderline personality disorders 1. can improve functioning and decrease relapse. Extreme negativism or mutism. E. E.Treatment of Schizophrenia A. G. Psychotic symptoms are generally mild and brief in duration. Non-bizarre delusions are present in the absence of other psychotic symptoms. B. and others. 4. Differential Diagnosis of Schizophrenia A. H. V. Psychosocial treatments in conjunction with medications are often indicated. Echolalia or echopraxia. Mood disorderwith psychotic features 1. Schizophreniform disorder. 2. or catatonic type. Duration of symptoms is between one day to one month. Daytreatment programs. D. B. Psychotic disorder due to a general medical condition. Brief psychotic disorder. C. multiple strokes. or dementia. or delusions. The criteria for schizophrenia is met. HIV. hepatic encephalopathy. D. In schizophrenia. Phencyclidine (PCP) may lead to both positive and negative symptoms. Included would be CNS infections. A complete discussion of the treatment of Schizophrenia can be found on . 2. F.lupus. with emphasis on social skills training. but it cannot be characterized as paranoid. Disturbances of mood are frequent in all phases of schizophrenia. Mood symptoms are present for a significant portion of the illness. Amphetamines and cocaine frequently cause hallucinations. Psychotic symptoms occur only during major mood disturbance (mania or major depression). Substance-induced psychotic disorder. paranoia. with no identifiable time of onset.3. Peculiar voluntary movements such as bizarre posturing. VI. Residual type Schizophrenia is characterizedbytheabsenceofprominent delusions. disorganized. Antipsychotic medications reduce core symptoms and are the cornerstone of treatment of schizophrenia. Undifferentiated typeSchizophrenia meets criteria for schizophrenia. 5. disorganized speech and grossly disorganized or catatonic behavior and continued negative symptoms or two or more attenuated positive symptoms. paranoid. but the duration of illness is less than six months. myxedema. Patterns of behavior are life-long.
Suicidal ideation. Electroconvulsive therapy is rarely used in the treatment of schizophrenia. Diagnosed when a manic or mixed episode occurs with psychotic features. First-degree biological relatives of schizoaffective disorder patients have an increased risk of schizophrenia as well as mood disorders. Depressive type. Clinical Features of Schizoaffective Disorder A. The lifetime prevalence is under one percent. B. Major depression may also occur. Ageneralmedical condition or substance use is not the cause of symptoms. they must be present for one week. Mood symptoms must be present for a significant portion of the illness. Bipolar Type. E. II. and major depressive symptoms must be present for two weeks. 3. If manic or mixed symptoms occur.Classification of SchizoaffectiveDisorder A. F. Patients who are a danger tothemselves or others require hospitalization. EpidemiologyofSchizoaffectiveDisorder A. but the symptoms are also associated withrecurrentor chronic mood disturbances. IV. Familytherapyand individual supportive psychotherapy are also useful in relapse prevention. DSM-IV Diagnostic Criteria A.especially withahistoryofacting on hallucinations. 4. The illness must also be associated with delusions or hallucinations for two weeks. manic episode. Symptoms ofschizophrenia are present. III. Indications for hospitalization 1. Schizoaffective disorder is an illness. or mixed episode. C. Schizoaffective Disorder I. B. 2. but may be useful when catatonia or prominent affective symptoms are present. D. Diagnosed if only major depressive episodes occur. without significant mood symptoms. Patients with command hallucinations to harm self or others should be evaluated for hospitalization. Psychotic symptoms and mood symptoms may occur independently or together. C. Psychotic symptoms prevent the patient from caring for his basic needs. . whichmeetsthe criteria for schizophrenia and concurrently meets the criteria for a major depressive episode. D. B.page 99. often secondary to psychosis. B. usually requires hospitalization.
Mood disorderwithpsychotic features. DifferentialDiagnosis of Schizoaffective Disorder A. D. mood stabilizers (eg. or negative symptoms. page 107).V. Hospitalization and supportivepsychotherapy may be required.Treatment of Schizoaffective Disorder A.disorganized speech.medications. For bipolar type. . In schizophrenia. Psychotic disorder due to a general medical condition.valproate or carbamazepine) are used alone or in combination withantipsychotics(see Mood Stabilizers. or dementia should be ruled out by medical history.lithium. grossly disorganized or catatonic behavior. page 111). Psychotic and mood symptoms of schizoaffective disorder can also bemimickedbystreet drugs. physical exam. DSM-IVDiagnosticCrteriaforSchizophreniform i Disorder A. Mood symptoms usually do not meet the full criteria for major depressive or manic episodes. delirium. Schizophrenia. and labs. The following criteriafor schizophrenia must be met: 1. Psychotic symptoms are treated with antipsychotic agents (see Antipsychotic Therapy. B. VI. The depressed phase of schizoaffective disorder is treated with antidepressant medications (see Antidepressant Therapy. Symptoms may include delusions. Delusional Disorder. Two or more symptoms for one month. Schizoaffective disorder and mood disorder with psychotic features must be excluded. In mood disorder with psychoticfeatures. E. Schizophreniform Disorder Patients with schizophreniform disorder meet full criteria for schizophrenia. Depressive symptoms can occur in delusional disorders. or toxins. Electroconvulsive therapy may be necessary for severe depression or mania. but psychotic symptoms of a delusional disorder are non-bizarre compared to schizoaffective disorder. Substance-Induced PsychoticDisorder. mood symptoms are relatively brief in relation to psychotic symptoms. D. page 99). E. the psychotic features occur only inthe presence ofa major mood disturbance. but the duration of illness is between one to six months.hallucinations. C. I. B. C. 2.
medication or toxic substances may cause symptoms that are similar to schizoaffective disorder. Differential Diagnosis of Schizophreniform Disorder A. Schizophreniform disorder with good prognostic features 1. Depressive symptoms may require antidepressants or mood stabilizers. Symptomatology must last for at least one month. Social and occupational functioning may or may not be impaired.2%. Good premorbid social and occupational functioning. Prevalence is the same in males and females. Schizophreniform disorder without good prognostic features ischaracterized by the absence of above features. is the same as schizophrenia. but less than six months. Hospitalization may be required if the patient is unable to care for himself or if suicidal or homicidal ideation is present. B. delirium. Lack of blunted or flat affect. B. Confusion often present at peak of psychosis. VI. 3. The differential diagnosisfor schizophreniform disorder is the same as forschizophrenia and includes psychotic disorder due to a general medical condition. V. C. Antipsychotic medication in conjunction with supportive psychotherapy is the primarytreatment(see Antipsychotic Therapy. B. Epidemiology of Schizophreniform Disorder A. B. D.3. Onset of psychosis occurs within four weeks of behavioral change. Lifetime prevalence of schizophreniform disorder is approximately 0.Classification of Schizophreniform Disorder A. Substance-induced symptoms or symptomsfrom a general medical condition have been ruled out. Substance abuse. III. such as amphetamines.Treatment of Schizophreniform Disorder A. Symptomatology. including positive and negative psychotic features. 4. IV. Clinical Features of Schizophreniform Disorder A. . page 99). II. Early and aggressive treatment is associated with a better prognosis. Depressive symptoms commonly coexist and are associated with an increased suicide risk. B. C. Concomitant use of drugs that can cause or exacerbate psychosis. 2. 4. may complicate the diagnostic process. or dementia. C.
Brief Psychotic Disorder with Marked Stressors is present if symptoms occur in relation to severe stressors (ie. I. 3. Clinical Features of Brief Psychotic Disorder A. BriefPsychoticDisorderwithPostpartum Onset occurs within four weeks of giving birth. B. The disorder is rare. The duration of symptoms is between one day and one month. B. EpidemiologyofBriefPsychoticDisorder A. At least one of the following: 1. disorganized speech or behavior. with marked functional impairment. B.Brief Psychotic Disorder Brief psychotic disorder is characterized by hallucinations. schizoaffective disorder. C. Grossly disorganized or catatonic behavior. Attentional deficits are common. The risk of suicide is increased in patients with this disorder. II. D. Emotional turmoil and confusion are often present. C. Duration of symptoms is between one day and one month. Psychotic symptoms are usually of brief duration (several days).Classification of Brief Psychotic Disorder A. 2.schizophrenia. In contrast. Disorganized speech. delusions. after which the patient returns to the previous level of functioning. . III. and younger individuals have a higher rate of illness. Patients with personality disorders have a higher risk for brief psychotic disorder. Delusions. especially in young patients. The disturbance is not caused by a mood disorder with psychotic features. C. C. B. diagnosis of schizophrenia requires a six-month duration of symptoms. Onset is usually sudden and may abate as rapidly as it began. with the average age of onset in the late twenties to early thirties. 4. E. Mood and affect may be labile. or other medical condition. Symptom onset is often rapid. DSM-IV Diagnostic Criteria for Brief Psychotic Disorder A. death of a loved one). Brief Psychotic Disorder without Marked Stressorsis presentifsymptoms occur without identifiable stressors. IV. Hallucinations. substance abuse.
Substance-InducedPsychotic Disorder 1. Alcohol or sedative hypnotic withdrawal may also mimic these symptoms. Substance abuse should beexcluded byhistoryand with a urine toxicology screen. 3.Treatment of Brief Psychotic Disorder A. Schizophreniform disorder must last for over a month and schizophrenia must have a six. such as lorazepam 1-2 mg every 4 to 6 hours.V. Psychotic Disorder Caused a General Medical Condition 1. especially if suicidal or homicidal ideation is present. Mood Disorder with Psychotic Features. SchizophreniformDisorderorSchizophrenia. A CBC can be used torule outdeliriumand psychosis caused byinfection. . C. B. RPR to rule out neurosyphilis. Supportive psychotherapy is indicated if precipitating stressors are present. cocaine and PCP mayproducesymptomsindistinguishable from brief psychotic disorder.This is especially important in elderly patients where the incidence of brief reactive psychosisislowcomparedtoyounger patients. 4.month duration. Rule out with history. 2. Brief psychotic disorder cannot be diagnosed if the full criteria for major depressive. Supportive psychotherapy is initiated after psychosis has resolved. D. Short-actingbenzodiazepines. Adjunctive benzodiazepinescan speed the resolution ofsymptoms. Brief hospitalization maybe necessary. 2. Amphetamine. Routine chemistry labs can be used toruleoutelectrolyte imbalances or hepatic encephalopathy. Differential Diagnosis of Brief Psychotic Disorder A. C.especially when there is a history of amnestic periods or impaired consciousness. Patients can also be very confused and impulsive. can be used as needed for associated agitation and anxiety. physical exam and labs. Consider a MRI or head CT scan to rule out a mass or neoplasm. B. such as risperidone (Risperdal) 2-4 mg per day. is usually indicated. HIV to rule out psychosis due to encephalitis in at-risk patients. An EEG should be considered to rule out seizure disorders (such as temporallobe epilepsy). A brief course of a neuroleptic. manic or mixed episode is present VI.
knowledge. Somatic type. IV. with prevalence of 0. C. Cognition and sensorium are intact. There is generally no disturbance of thought processes. Mean age of onset is generallybetween 35-45. and this disorder may cause significant impairment in social and occupational functioning. Mixed type. such as loosening of associations or tangentiality. Involves delusions that the individual is being harassed. I. Persecutory type. B. Involves delusions of a physical deficit or medical condition. E. Hallucinations are not prominent unless delusional disorder is of the somatic type. age of onset is highly variable.grosslydisorganized or catatonic behavior.Classification of Delusional Disorder A. The delusion must be plausible. Involves delusions that another person is in love with the patient. Differential Diagnosis of Delusional . The insight of patients into their illness is generally poor. D. the total duration of mood pathology is brief compared to the duration of the delusions. however. The incidence in males and females appears equal. D. Clinical Features of DelusionalDisorder A. or negative symptoms of schizophrenia (tactile or olfactory hallucinations maybe present if related to the delusional theme). C.Delusional Disorder Delusional disorder is characterized by the presence of irrational. Behavior and functioning are not significantly bizarre or impaired. such as believing that someone is trying to harm them. The presence of a non-bizarre delusion is the cardinal feature of this disorder. Non-bizarre delusions have lasted for at least one month.wealth. III. F. E. D. Involves delusions of at least two of the above without a predominate theme. II. Epidemiologyof Delusional Disorder A. untrue beliefs. Involves delusions that an individual's partner is unfaithful.03%. identity or relationship to a famous person or religious figure. DSM-IV Diagnostic Criteria for Delusional Disorder A. B. C. B. Grandiose type. Delusional disorder is uncommon. disorganized speech. Jealous type. Involves delusions ofexaggerated power. This disorder is characterized by the absenceofhallucinations. B. Patient’s thoughtprocessesand thought contentare normalexceptwhen discussing the specific delusion. V. If mood episodes have occurred. Erotomanic type.
B. historyand physical examination can usuallydistinguish these conditions. patients with delusional disorder do not meet full criteria for a mood episode and the duration of mood symptoms is brief compared to delusional symptoms. Symptoms may be identical to delusional disorder if the patient has ingested amphetamines or cocaine. Schizophrenia/Schizophreniform Disorder. D. . Psychotherapy. 2. see page 121. C. Substance-InducedPsychotic Disorder 1. Although mood symptoms and delusions may be present in both disorders. Delusional disorders are often refractory to antipsychotic medication. 2. Psychotic Disorder Due to a General Medical Condition 1.Delusional disorder is distinguished from these disorders by a lack of other positive or negative symptoms of psychosis. Cognitive exam. VI. including family or couples therapy. Substance abuse shouldbeexcluded by history and toxicology.Treatment of Delusional Disorder A. may offer some benefit.Disorder A. B. Simple delusions of a persecutory or somatic nature are often present in delirium or dementia. Mood Disorders With Psychotic Features. References References.
B. F. 1. Feelings of hopelessnessand helplessness are common. 4. D. Decreased libido is common. Manic Episode. II. Psychomotor agitation can be severe. ClinicalFeatures of Depressive Episodes A. C. B. E. Types of Mood Disorders a. At least five of the following symptoms for at least two weeks duration. Pervasive anhedonia. 3. C. Psychomotor agitation or retardation. Mood episodes are comprised off periods when the patient exhibits symptoms of a predominant mood state. D. DSM-IV Diagnostic Criteria A. Cannotbecausedbyamedical condition. Pervasive fatigue or loss of energy.Mood Disorders I. difficultysleeping and decreased energy. i 8. B. Pervasive depressed mood. Major Depressive Episode. Excessivegultorfeelingsofworthlessness. Other Mood Disorders. Early morning awakening with difficulty or inability to fall back asleep is typical. c. Sleep disturbance. At least one symptom is depressed mood or loss of interest or pleasure. only anxiety and irritability are displayed. Mood episodes are not diagnostic entities. Types of Mood Episodes a. Occasionallyno subjective depressed mood is present. Major Depressive Episodes Major depressive episodes are characterized by persistent sadness. Mood disorders are classified as follows: 1. Hypomanic Episode. Categorization of Mood Disorders A. Symptoms cannot be caused by bereavement. E. 5. 9. Depressive Disorders. Significant change in weight. Mood episodes are classified as follows: 1. . C. The mood disorders are clinical diagnoses defined by the presence of characteristic mood episodes. medication or drugs. b. Bipolar Disorders. Symptoms must cause significant social or occupational dysfunction or significant subjective distress. b. Difficulty concentrating. d. I. Mixed Episode. often associated with somatic symptoms. Mustbe a change from previousfunctioning. 7. Recurrent thoughts of death or thoughts of suicide. 6. 2. c. such as weight loss.
The symptoms cannot be caused by a medical condition. Clinical Features of Manic Episodes A. Recklessbehaviorwthnegativeconsequences i is common (eg. Frank delusions and hallucinations may occur. 7. Obsessive rumination about the past or specific problems is common. Distractibility. I. During the period of mood disturbance. 3. B. D. Inability to sleep can be severe and . G. Increased goal-directed activity or psychomotor agitation. and they are frequently nihilistic in nature. Manic Episodes I. D. C. E. II. At least one week of abnormally and persistently elevated. J. Patientsmayseek outconstantenthusiastic interaction with others. excessive spending.orhave required hospitalization to prevent harm to self or others. frequently using poor judgmentin those interactions. Family history of mood disorder or suicide is common. B. The patient has been more talkative than usual or feels pressure to keep talking. Inflated self-esteem or grandiosity. sexual indiscretion). DSM-IV Diagnostic Criteria A. expansive or irritable mood (may be less than one week if hospitalization is required). K. Flight of ideas (jumping from topic to topic) or a subjective sense of racing thoughts.sexual promiscuity). Increased psychomotor activity can take the form of excessive planning and participation. which are ultimately nonproductive. Patients mayappear demented because of poor attention. C. or psychotic features are present. Preoccupation with physical health may occur. E. H. 2. 4. Guilt may become excessive and may appear delusional. and indecisiveness. shopping sprees. Decreased need for sleep. poor concentration. at least three of the following have persisted in a significant manner (four if mood is irritable): 1. The most common presentation is excessive euphoria. Excessive involvement in pleasurable activities with a high potential for painful consequences (ie. medication or drugs. but some patients may present with irritability alone.F. Does not meet criteria for a mixed episode. 5. Symptoms must have cause marked impairment in social or occupational functioning. 6.
which is hallmark of a manic episode. medication or drugs. DSM-IV Diagnostic Criteria A. most frequently with paranoid features. 6. K. L. Decreased need for sleep. II.does notrequirehospitalization. At least 4 days of abnormally and persistently elevated. Increased goal-directed activity or psychomotor agitation. The mood disturbance and change in functioning is noticeable to others. Patients maybecome grosslypsychotic. The patient is more talkative than usual and feels pressure to keep talking. D. Grandiose delusions are common. 2. C. Distractibility. Excessive involvementin pleasurable activities that have a high potential for painful consequences (ie. E. 3. Flight of ideas can result in gross disorganization and incoherence of speech. Clinical Features of Hypomanic Episodes A. Symptoms cannot be due to a medical condition. 7. Hypomanic Episodes I. F. and no psychotic features are present. Flight of ideas (jumping from topic to topic) or a subjective sense of racing thoughts. Patients may become assaultive. and difficulty to interrupting these patients is common. H. and the patient may become suicidal. particularly if psychotic. Speech is pressured. The change in functioningisuncharacteristic of the patient’s baseline but does notcause marked social or occupational dysfunction. Dysphoria is common at the height of a manic episode. . Hallucinations and delusions are not seen in hypomania. The majordifferencebetween hypomanic and manic episodes is the lack of majorsocial and/or occupational dysfunction in hypomania. 4. expansive or irritable mood. loud and intrusive.sexual promiscuity). I. Inflated self-esteem or grandiosity. 5. G.persist for days. During the period of mood disturbance at least three of the following have persisted in a significant manner (four if mood is irritable): 1. J. Patients frequently lack insight into their behavior and resist treatment. Lability of mood is common. B.
eatingdisorders.require hospitalization. Organic factors have been excluded (medical conditions. Theyfrequentlypresent with agitation. with a 2:1 female-to-male ratio. Clinical Features of Mixed Mood Episodes A. Hospitalization may be necessary for acutely suicidal patients. DSM-IV Diagnostic Criteria for Major Depressive Disorders A. such as myocardial infarction. Epidemiology of Major Depressive Disorder A. C. allowing patients to follow through on suicidal ideas. B. Lack of initiative and poor energy can improve prior to improvement in mood. Common coexisting diagnoses include panic disorder. DSM-IV Diagnostic Criteria A. hypomanic. Major depressive disorder has a high mortality. Patients subjectivelyexperience rapidly shifting moods. C. This rises to 70% after two episodes and 90% after three episodes. III. and diabetes.appetite disturbance and insomnia Major Depressive Disorder I. These disorders should be excluded by the clinical history. Patient meets criteria for both for at least one week. Historyof one or more Major Depressive Episodes. E.suicidality. Suicide risk is most closely related to the degree of hopelessness a patient is experiencing and not to the severity of depression. II. The disorder often follows an episode of severe stress. Suicide risk may increase as the patient begins to respond to treatment.Mixed Mood Episodes I. B. B. medications. Major depressivedisorderoftencomplicates the presentation and treatment of patients with medical conditions. such as loss of a loved one. D. B. 15% suicide rate. . II. All patients should be asked about suicidal ideation as well as intent. or mixed episodes. drugs). Clinical Features of Major Depressive Disorder A. psychosis. Approximately 50% of patients who haveasingleepisode ofmajor depressive disorder will have a recurrence. or psychotic features are present.substance-related disorders. No history of manic. Symptoms are severe enough to cause marked impairmentinoccupational or social functioning. Prevalence is approximately 3-6%. B. stroke.
Major Depressive Disorder with Catatonic Features Accompanied by at least two of the following: 1. Functioning returns to the premorbid level between episodes in approximately two-thirds of patients. Full remissions occur ata characteristic time of year. F. IV. 3. Chronic patternof rejection sensitivity. Mood is worse in the morning. Depression is accompanied by hallucinations or delusions. Extreme negativism or mutism. D. 3. Significant weight gain.C. Major Depressive Disorder with Postpartum Onset. E. Bizarre or inappropriate posturing. C. Major Depressive Disorder.Classification of Major Depressive Disorder A. 4. Major Depressive Disorder with Psychotic Features. Excessive purposeless motoractivity. Significant weight loss. Excessive guilt. “Heavy”feeling in extremities (leaden paralysis). Early morning awakening. 4. Qualityofmood is distinctlydepressed. D.Onset ofepisode within four weeks of parturition. resulting in significant social or occupational dysfunction. 5. Fulldiagnosticcriteriafor major depressive disorder have been met continuously for at least 2 years. 2. 3. 4. Depression is accompanied by mood reactivity and at least two of the following: 1.whichmaybemood-congruent (content is consistent with typical depressive themes) or mood incongruent (content does notinvolve typicaldepressive themes). Major Depressive Disorder with Seasonal Pattern 1. Marked psychomotor slowing. 2. Hypersomnia. stereotyped movement. or facial grimacing. G. 5. B. 2. 6. Motor immobility or stupor. Major Depressive Disorder with Melancholic Features. Major Depressive Disorder with Atypical Features. Echolalia or echopraxia. Depression is accompanied by severe anhedonia or lack of reactivityto usuallypleasurable stimuli and at least three of the following: 1. 5. The disorder is two times more common in first-degree relatives of patients withmajor depressive disorder compared to the general population. Recurrent episodes of depression with a pattern of onset at same time each year. . Does not meet criteria for major depressive disorder with melancholic or catatonic features. 2.Chronic.
2. compared to patients with psychotic disorders. Subjectivedepression mayaccompany acute psychosis. The medical historyand examination can suggest possible medical . the mood symptoms generally precede the onset of psychotic symptoms. at least twoseasonal episodes haveoccurred. 2. V. Cognitive deficits due to a mood disorder may appear very similar to dementia. Differential Diagnosis of MajorDepressive Disorder A. Schizophrenia and Schizoaffective Disorder 1. a trial of antidepressants maybe useful because depression is reversible and dementia is not. 3. Differentiation of dementia from depression can be very difficult in the elderly. E. B. Adjustment Disorderwith Depressed Mood 1. Normal bereavement should not present with depressive symptoms. and no nonseasonal episodes have occurred. Dementia and depression may present with complaints of apathy. the depression should be the focus of treatment because it carries a higher morbidity and mortality. Bereavement 1. Anxiety Disorders 1. “Pseudodementia” is defined as depression that mimics dementia. The premorbid and inter-episode functioning are generally higher in patients with mood disorders. however. D. Severe psychotic depressionmaybedifficulttodistinguish from a primary psychotic disorder. C. In psychotic depression. Dementia 1. Symptoms of anxiety frequently coexist with depression. poor concentration. 2. A stressful event may precede the onset of a major depressive episode. Seasonal episodes outnumber non-seasonal episodes. and impaired memory. 2.3. dysphoria related to a stressor that does not meet the criteria for major depressive episode should be diagnosed as an adjustment disorder. 4. which cause severe functional impairment lasting more than two months. Over a two-year period. Antidepressants are often effective in treating anxiety disorders. When the diagnosis is unclear. When anxiety symptoms coexist with depressive symptoms. 3. Bereavement may share many symptoms of a major depressive episode. 4.
the patient's age. C. 2. suicide potential. B. or toxin exposure should be completed. This diagnosis applies when the mooddisorder is a directphysiological consequence of the medicaldisorder and is not an emotional response to a physical illness. VI. another trial of that medication is indicated. Side effects (especiallysedation and anticholinergic effects) are worse during the first month of therapy and usuallydiminish after four weeks. SSRIs are safer than heterocyclic antidepressants in overdose. Substance-Induced Mood Disorder 1. The medical historyand examination may suggest potential medical conditionswhich present with depressive symptoms. 2. antihypertensives. Alcohol. 3. and anycoexisting diseases or medications.If the patient or a first-degree relative has had a previous treatment response to a given medication. a. but patients rarelydescribeimprovement .and oralcontraceptives can all cause depressive symptoms.Pharmacotherapy of Depression A. Withdrawal from sympathomimetics or amphetamines may cause a depressive syndrome. making them preferable for suicidal patients. F. which isnotsimplya reaction to the disability of the disease. Selecting an Antidepressant Agent 1.seeAntidepressant Therapy. sedatives. There is no reliable method of predicting which patients will respond to a specific antidepressant based on clinical presentation. drugs of abuse. 3.or organic causes of dementia. All antidepressant drugs have shown equal efficacy. G. For example. Agent selection is also based on the expected tolerance to side effects. page 107. Parkinson’s disease is oftenassociated with a depressive syndrome. drug abuse. Careful examination ofall medications. Classification of Antidepressant Agents 1. b. Mood Disorder Due to a General Medical Condition 1. but the various agents have different side-effect profiles. 2. b. Heterocyclic Antidepressants a. Selective-serotonin reuptake inhibitors (SSRIs) are much safer in patients with a history of cardiac disease. For a complete discussion of the treatmentofDepression. Early in the treatment course. patients may sleep better.
in mood before 3-4 weeks. e. SSRIs include fluoxetine(Prozac). b. 3. Although many patients take SSRIswithnoadverseconsequences. It is also useful . and sexual dysfunction. The short half-life of bupropion requires multiple dailydoses. GI upset. Nefazodone(Serzone):Nefazodone is a serotonergic antidepressant. and it can have a calming or antianxiety effect in some patients. a therapeutic dose may be achieved earlier than with tricyclics.complicatingcompliance. c. c. the most frequent side effects are insomnia. Selective-Serotonin Reuptake Inhibitors (SSRIs) a. Useofheterocyclic antidepressants in the elderly may be limited bythe sensitivityof these patients toanticholinergic and cardiovascular side effects. SSRIs. nervousness and nausea are common. Another advantage of SSRIs is that they require less dosage titration. headache. fluvoxamine (Luvox). c. allow once-daily dosing and present less danger from overdose because theylackthecardiovascular toxicity of the tricyclics.and is particularly useful in patients who have had sexual impairment from other drugs.andescitalopram (Lexapro). Venlafaxine (Effexor. Wellbutrin SR):Bupropion is a mildlystimulating antidepressant. b. 2. Only minimum quantities of tricyclics should be prescribed because of the potential of tricyclicstocause a fatal overdose in suicide-prone patients. At higher doses it can elevate diastolic blood pressure and requires monitoring of blood pressure. It tends to be more sedating than the SSRIs. There is a low incidence of sexual dysfunction and decreased liability to precipitate mania. Bupropion (Wellbutrin. SSRIs are commonly used as first-line agents as well as secondarychoices for depression thatdoes not respond to tricyclics. Thus. d. Insomnia. paroxetine (Paxil). anxiety. d. citalopram(Celexa). but it is not considered a SSRI becauseofother receptor effects. sertraline (Zoloft). agitation. Atypical Agents a. with their comparatively benign side-effect profile. Effexor XR): Venlafaxine is a selective inhibitor of norepinephrine and serotonin reuptake.
Marked sedation often occurs. b. Drug Interactions. DSM-IV Diagnostic Criteria A. 4. Depressed mood is present for most of the day. Poor appetite or overeating.000 patient-years of nefazodone exposure). 6. after ETC. Poor concentration or difficulty making decisions. A wide variety of psychotherapies are effective in the treatment of major depressive disorder. SideEffects. Presence of at least two of the following: 1. 3. especially if there is a high risk for suicide or insufficient time for a trial of medication. which usually decreases over the first weeks of treatment. and depression has been present for at least two years.000-300. 4. Combined pharmacotherapy and psychotherapy is the most effective treatment for major depressive disorder. ElectroconvulsiveTherapyforDepression (also see Electroconvulsive Therapy. Dysthymic Disorder I. Contraindications and dietary restriction discourage common use. Low self-esteem.in patients who experience sexual impairment with other antidepressants. There is a lowincidence of sexual dysfunction. 2. c. Rare cases ofliver failurehave been reported with nefazodone (one case of death or liver transplant per 250. meperidine (Demerol). especiallycognitive behavioral psychotherapy and insight oriented psychotherapy. PsychotherapyforMajorDepressive Disorder A. Insomnia or hypersomnia.Coadministration of epinephrine. A tyramine-free dietisrequiredtopreventhypertensive crisis. Low energy or fatigue. Weight gain is also common (average of 2 kg). for more days than it is not present. . and SSRIs can be life-threatening. d.Orthostatichypotension is common. Monoamine Oxidase Inhibitors a. B. VII. page 119). Mirtazapine(Remeron):Mirtazapine is a selective alpha-2 adrenergic antagonist. Hopelessness. VIII. ECT is a safe and very effective treatment for depression. which enhances noradrenergic and serotonergic neurotransmission. 5. B.
4. B. Clinical Featuresof Dysthymic Disorder A. Symptoms do not occur with a chronic psychotic disorder. and decreased productivity. Over the two-year period. 2.Classification of Dysthymic Disorder A. social withdrawal. C. appetite orpsychomotor behavior are less common than in major depressive disorder. less severe depressive symptoms.Dysthymia leads to chronic. Episodes of major depression may occur after the first two years of the disorder. Achronic patternofrejection sensitivity. Dysthymia with Atypical Features is accompanied by mood reactivity and at least two of the following: 1.C. MajorDepressiveDisorder. IV. 3. C. F. Patients often complain of multiple physical problems. Substance-Induced Mood Disorder. V. . Hypersomnia. H. No major depressive episode has occurred during the first two years of the disturbance. the patient has never been without symptoms for more than two months consecutively. feelings of inadequacy. Early Onset Dysthymia: Onset occurs before age 21. II. D. with a female-to-male ratio of 3:1. Epidemiologyof Dysthymic Disorder A. B. The most common symptoms are loss of pleasure in usually pleasurable activities. which may interfere with occupational or social functioning. Psychotic symptoms are not present. Symptoms of dysthymic disorder are similar to those of major depression. B. D.” III. “Leaden” paralysis. which often results in significant social or occupational dysfunction. hypomanic or mixed episode. or evidence of cyclothymia is present. Major Depression usually has one of more discrete episodes. Symptoms are not due to substance use or a general medical condition. Dysthymia that occurs prior to the onset of major depression has a worse prognosis than major depression without dysthymia. No manic. E. Changesinsleep. Symptoms cause significant social or occupational dysfunction or marked subjective distress. Late Onset Dysthymia: Onset occurs at age 21 or older. Differential Diagnosis of Dysthymic Disorder A. Onset usually occurs in childhood or adolescence. irritability. C. comparedtoMajor Depression. guilt. The combination of dysthymia and major depression is known as “double depression. B. Lifetime prevalence is 6%. G. characterized by a feeling of being heavy or weighted down physically. Significant weight gain.
Psychotherapy:Cognitivepsychotherapy may help patients deal with incorrect negative attitudes about themselves. and dysthymia should not be diagnosed if symptoms occur only during psychosis. have failed.Cushing’s disease. as can chronic use of amphetamines or cocaine. Depressive symptoms are common in chronic psychotic disorders. . benzodiazepines and other sedative-hypnotics can mimic dysthymia symptoms. Personality disorders frequentlycoexist withdysthymic disorder.Depressivesymptoms consistent with dysthymia may occur in stroke. beta-adrenergicblockersand isotretinoin (Accutane) have also been linked todepressivesymptoms. B. page 107) C. is often effective.oral contraceptives. Huntington’s disease. Insight oriented psychotherapy may help patients resolve early childhood conflict. These disorders should be ruled out with a history. nefazodone or bupropion. C. If these or other antidepressants. (For a complete discussion of antidepressant therapy. 150 to 200 mg per day. Antidepressants. methyldopa. Personality Disorders. E. Anabolic steroids. pancreatic carcinoma. vitamin B12 deficiency. and HIV. Mood Disorder Due to a General Medical Condition.Alcohol. Psychotic Disorders. VI. SSRIs are most often used. Combined psychotherapy and pharmacotherapy produces the best outcome. Many patients respond well to antidepressants. such as venlafaxine. Parkinson’s disease. which may have precipitated depressive symptoms. physical examination. Hospitalization is usually not required unless suicidality is present. then a tricyclic antidepressant. and labs as indicated.hypothyroidism. D.Substance-Induced Mood Disorder should be excluded with a careful historyof drugs of abuse and medications.Treatment of Dysthymic Disorder A. multiple sclerosis. such as desipramine.
child abuse. D. The male-to-female ratio is 1:1 C. Bipolar I disorder. F. excessive debt. IV. C.5-1. job loss. Mixed episodes are more likely in younger patients. Bipolar I disorder with a rapid cycling pattern carries a poor prognosis and mayaffect up to 20% of bipolar patients. With psychotic features. 3. or treatment for depression. I. With postpartum onset. B.Bipolar I Disorder Bipolar I Disorder is a disorder in which at least one manic or mixed episode is present. drugs of abuse. or divorce. The disorder is commonlyaccompanied by a history of one or more major depressive episodes. Manic episodes can result in violence. Common comorbid diagnoses often include substance-related disorders. II. D. C. B. toxins. 4. The most recent episode can be further classified as follows: 1. The first episode in males tends to be a manic episode. hypomanic. Symptoms cannot be caused by a psychotic disorder. eating disorders. Without psychotic features. .5%. Epidemiology of Bipolar I Disorder A. III. One or more manic or mixed episodes. B. Bipolar I Disorder with Rapid Cycling 1. First-degree relatives have higher rates of mood disorder. E. Classification of bipolar I disorder involves describing the current or most recent mood episode as either manic. The suicide rate of bipolar patients is 10-15%. The lifetime prevalence of bipolar disorder is approximately 0. mixed or depressive (eg. while the first episode in females tends to be a depressive episode. medication. Ninety percent of patients who have a single manic episode will have a recurrence.Classification of Bipolar I Disorder A. Clinical Features of Bipolar I Disorder A. B. Bipolar disorder has a 70% concordance rate among monozygotic twins. With catatonic features. DSM-IV Criteria for Bipolar I Disorder A. Episodes occur more frequently with age. and attention deficit hyperactivity disorder. Diagnosis requires the presence of at least four mood episodes within one year. C. 2.most recent episode mixed). G. D. but a major depressive episode is not required for the diagnosis. Manic or mixed episodes cannot be due to a medical condition.
lupus. 3. A subsequent major depressive episode or manic episode that initially presents with mood symptoms prior to the onset of psychosis. B. but they should only be used in . B. The clinical presentation of a patient at the height of a manic episode may be indistinguishable from that of an acute exacerbation of paranoid schizophrenia. indicates that a mood disorder. Cushing’s. 3. 2. Cyclothymic Disorder. and H2 blockers (eg. or the patient must switch to an opposite episode. Differential Diagnosis of Bipolar I Disorder A. butitisgenerallyused after conventional pharmacotherapy has failed or is contraindicated. or major depression. Mood Disorder Due to a General Medical Condition. page 111). depressive episodes. Assessment of suicidality is essential. ECT is very effective for bipolar disorder (depressed or manic episodes).Treatment of Bipolar I Disorder A. are effective for acute treatment as well as the prophylaxis of mood episodes. hypomanic. Hospitalization may be necessary for either Manic or Depressive mood episodes. Rapid cycling mood episodes may include major depressive. hyperthyroidism. manic. rather than a psychotic disorder. Pharmacotherapy 1. If the history is unavailable or if the patient is having an initial episode. C. 2. D. This disorder may cause manic-like episodes that do not meet the criteria for manic episode. The patient must be symptom-free for at least two months between episodes. multiple sclerosis. and brain tumors. (Also see Mood Stabilizers. is present. cocaine. mpat amphetamines. Psychotic Disorders 1. VI. such as lithium and the anticonvulsants. Mood stabilizers. or mixed episodes 3. Common organiccausesofmaniaincludesy homimetics. A family history of either a mood disorder or psychotic disorder suggests the diagnosis of bipolar disorder or psychotic disorder respectively. C. Substance-Induced Mood Disorder. cimetidine). V.2. steroids. The effects of medication or drugs of abuse should be excluded. Medical conditions that maypresent with manic symptoms include AIDS. suicidal ideation and intent should be evaluated. it may be necessary to observe the patient over time to make an accurate diagnosis. Antidepressants may be used for treatment of major depressiveepisodes.
One ormore majordepressiveepisodes and at least one hypomanic episode. Psychotherapy 1. attention deficit hyperactivity disorder. Bipolar II Disorder I. Bipolar IIDisorder with Rapid Cycling 1. The rapid cycling pattern carries a poor prognosis. C. Social and occupational consequences of bipolar II can include job loss and divorce. The lifetime prevalence of bipolar II is 0. and borderline personality disorder.Olanzapine (Zyprexa) is FDA approved for the treatment ofacutemania. and episodes tend to occur more frequently with age. II. toxins. DSM-IV Diagnostic Criteria of Bipolar II Disorder A. B. Episodes with psychotic features.conjunction with a mood stabilizer to prevent precipitation of a manic episode. Therapy aimed at increasing insight and dealing with the consequences of the manic episodes may be very helpful. which can be hypomanic or depressive. IV. B. Mood episodes cannot be caused by a medical condition. maybe necessary. Epidemiology.such as clonazepam and lorazepam (for severe agitation). Antidepressants mayinduce rapid cycling. These patients have a suicide rate of 10-15%. drugs of abuse. C. Episodes with catatonic features. Symptoms cannot be caused by a psychotic disorder. Episodes with post partum onset. 2. III. D. Hypomanic episodes tend to occur in close proximitytodepressiveepisodes. Common comorbid diagnoses include substance-related disorders. It is more common in women than in men. Family or marital therapy may also help increase understanding and tolerance ofthe affected familymember.Otheratypical antipsychotics are likely to have similar efficacy. D. or treatment for depression. The most recent episode can be further classified as follows: 1. Clinical Features of Bipolar II Disorder A. 3. 4. medication. Episodes without psychotic features.Classification of Bipolar II Disorder A. Adjunctive use of antipsychotics (if psychosis is present) or sedating benzodiazepines. 4. This diagnosis requires the presence of at least four mood episodes within one year. eating disorders. Classification of bipolar II disorder involves evaluation of current or most recent mood episode. C. Episodes may include . 2. B.5%.
E. The effects of medication. manic. During the two-year period. pancreatic carcinoma. and brain tumors. mania or mixed states were present. I.Treatment of Bipolar II Disorder. Symptoms are notcaused bysubstance use or a general medical condition. Patients frequently have coexisting . ClinicalFeaturesof Cyclothymic Disorder A. DSM-IV Diagnostic Criteria A. the patient has not been symptom-free for more than two months at a time. hyperthyroidism.Cushing’s disease.major depressive. but they are of a lesser magnitude and cycles occur at a faster rate. II. Symptoms are not accounted for by schizoaffective disorder and do notcoexistwithschizophrenia. During the two-year period. D. Cushing’s. Treatment is similar to that of Bipolar I disorder. Differential Diagnosis of Bipolar II Disorder A. The patient must be symptom-free for at least two months between episodes. B. or mixed type episodes. page 111). Depressivesymptoms consistent with dysthymia may occur in stroke.hypothyroidism. described above (See Mood Stabilizers. 2. or the patient must display a change in mood to an opposite type of episode. Symptoms are similar to those of bipolar I disorder.Depressive episodes do not reach the severity of major depression. F. lupus. B. no episodes of major depression. Cyclothymic Disorder. Manyperiods ofdepression and hypomania. vitamin B12 deficiency. Parkinson’s disease. occurring for atleasttwo years. These patients will exhibit mood swings that do not meet the criteria for full manic episode or full major depressive episode. Mood Disorder Due to a General Medical Condition. V. hypomanic. VI. B. C. drugs of abuse. C. or toxin exposure should be excluded. and HIV. The treatment of Bipolar II disorder includes a mood stabilizer and an antidepressant if depression is present. Substance-Induced Mood Disorder. Manic symptoms can be associated with AIDS. Symptoms cause significant distress or functional impairment.schizophreniform disorder. or any other psychotic disorder. Cyclothymic Disorder Cyclothymic disorder consists of chronic cyclical episodes of mild depression and symptoms of mild mania. Huntington’s disease. multiple sclerosis. delusional disorder.multiplesclerosis.
Cushing’s disease. C. page 111).lupus. Thirty percent of patients have a family history of bipolar disorder. Patients with bipolar type IIdisorder exhibit hypomania and episodes of major depression. and women are affected more than men by a ratio of 3:2. Substance-InducedMoodDisorder/Mood Disorder Due to a General Medical Condition. histrionic.Cushing’s.multiple sclerosis. pancreatic carcinoma. IV. Depressive episodes must be treated cautiouslybecause ofthe risk ofprecipitating manic symptoms with antidepressants (occursin50%ofpatients). borderline.Differential Diagnosis of Cyclothymic Disorder A. B. Cyclothymic disorder often coexists with borderline personality disorder. V. Epidemiologyof Cyclothymic Disorder A.substance abuse. E. (Also see Mood Stabilizers. narcissistic) can be associated with marked shifts in mood. Hypomanic symptoms canbe associated with AIDS. . One-third of patients develop a severe mood disorder (usually bipolar II). and HIV. Treatment of Cyclothymic Disorder A. The onset occurs between age 15 and 25.Antidepressants can also increase the rate of cycling. The prevalence is 1%. Personality disorders may coexist with cyclothymic disorder. The clinical use of mood stabilizers is similar to that of bipolar disorder. Huntington’s disease. and lithium is effective in 60% of patients. Patients often require supportive therapy to improve awareness of their illnessand todealwiththe functional consequences of their behavior. Patients are often treated concurrently with antimanics and antidepressants. see page 121. B. References References.hypothyroidism. but cyclothymic disorder constitutes 5-10% of psychiatric outpatients. B. C. Occupational and interpersonal impairment is frequent and usually a consequence of hypomanic states.Depressivesymptoms consistent with dysthymia may occur in stroke. Bipolar II Disorder. multiple sclerosis. Personality Disorders (antisocial. C. Parkinson’s disease. hyperthyroidism. D. vitamin B12 deficiency. and brain tumors. III. C. Mood stabilizers are the treatment of choice.
marriage. health. F. Other features often include insomnia. 4. Easy fatigability. jobs. I. Restlessness or feeling on edge. E. including autonomic hyperactivity and hypervigilance. Substance abuse maybe acomplication . E. Symptoms are notcaused bysubstance use or a medical condition. Mooddisorders. unlike the intermittent terror that characterizes panic disorder. Irritability. 2.light-headedness. muscle twitches.dizziness. The anxiety is difficult to control. D. The focus of anxiety is not anticipatory anxiety about having a panic attack. Difficulty concentrating. Chronic worry is a prominent feature of generalized anxiety disorder. 5. Excessive anxiety or worry is present most days during at least a six-month period and involves a number of life events. It is characterized by unrealistic or excessive anxiety and worry about two or more life circumstances for at least six months.dysphagia. B. Sleep disturbance. Up to one-fourth of GAD patients develop panic disorder. dry mouth. The anxiety or physical symptoms cause significant distress or impairment in functioning.Anxiety Disorders Generalized Anxiety Disorder Generalized anxiety disorder (GAD) is the most common of the anxiety disorders. and the safety of children. II. trembling. D. difficultybreathing. occur most days. Excessive worry and somatic symptoms. Clinical Features of Generalized Anxiety Disorder A. clammy hands. B.and symptoms are not related to a mood or psychotic disorder. dyspepsia) commonly coexist with GAD. Patients often complain that they “can't stop worrying. DSM-IV Diagnostic Criteria for Generalized Anxiety Disorder A. and diarrhea. Muscle tension. and a heightened startle reflex. muscle aches and soreness. C.” which mayrevolve around valid concerns about money. urinaryfrequency. 3. C. abdominal pain. 6. as in panic disorder.substance-andstress-related disorders (headaches. irritability. Patients may also report palpitations. About 30-50% of patients with anxiety disorders will also meet criteria for major depressive disorder. Drugs and alcohol may cause anxiety or may be an attempt at self-treatment. At least three of the following: 1.
Epidemiology A. Substance-Induced AnxietyDisorder. then GAD cannot be diagnosed. congestiveheartfailure.however.and the diagnosis of GAD should be made only if the anxiety is unrelated to the other disorders. or cocaine can cause anxietysymptoms. Alcohol or benzodiazepine withdrawal can mimic symptoms of GAD. or if an anorexic patient has anxiety about weight gain. Venlafaxine is a first-line treatment for GAD.of GAD. and hypoglycemia.Obsessive-Compulsive Disorder. Urine drug screen and urinary catecholamine levels may be required to exclude specific disorders. The combination of pharmacologic therapy and psychotherapy is the most successful form of treatment. may produce significant anxiety and should be ruled out as clinicallyindicated. Substancessuchascaffeine.pulmonaryembolism. C. GAD should not be diagnosed in panic disorder if the patient has excessive anxiety about having a panic attack. VI. onset after age 20 may sometimes occur. 2. B. B. Hyperthyroidism. These disorders should be excluded byhistory and toxicology screen. C. Most patients report excessive anxiety during childhood or adolescence. Many psychiatric disorders present with marked anxiety. III. Other Studies. Effexor XR can be started at75 mg perday. If anxiety occurs only during the course of the mood or psychotic disorder. Laboratory Evaluation of Anxiety A. Excessive worryand anxietyoccurs inmanymood and psychotic disorders. Serum glucose. Mood and Psychotic Disorders 1.amphetamines. cardiac arrhythmias. Panic Disorder. IV. Pharmacotherapy of Generalized Anxiety Disorder 1. 2.Hypochondriasis and Anorexia Nervosa 1. Anxiety Disorder Due to a General Medical Condition. B. electrocardiogram. calcium and phosphate levels. and thyroid studies should be included in the initial workup of all patients. Venlafaxine (Effexor and Effexor XR) a. For example. however. D.SocialPhobia. patients with severe anxiety or panic attacks should be . V. Lifetime prevalence is 5%. The female-to-male sex ratio for GAD is 2:1.Differential Diagnosis of Generalized Anxiety Disorder A.Treatment of Generalized Anxiety Disorder A. B.
Buspirone may have some antidepressant effects. An antidepressant is the agent of choice when depression coexists with anxiety. Long-term useofbenzodiazepines should be reserved for patients who have failed to respond to venlafaxine (Effexor).started at 37. Benzodiazepines are veryuseful for treating anxiety during the period in which ittakes buspirone or antidepressants to exert their effects. Venlafaxine usually requires several weeks to achieve efficacy and an adequate trial should last for 4-6 weeks. It lacks sedativeeffects. Benzodiazepines a. SSRIs. SSRIs appear to have similar efficacytovenlafaxine and should also be considered as a first-line therapy. Benzodiazepines . 3. Selective-serotonin reuptake inhibitors and tricyclic antidepressants are widely used to treat anxiety disorders.withsubsequent tapering of the benzodiazepine after 2-4 weeks. 2. Buspirone usually requires 3-6 weeks at a dosage of 10-20 mg tid for efficacy. b. b. Combinedbenzodiazepine-buspirone therapymaybeused for generalized anxietydisorder.5 mg per day. c. Other Antidepressants a. c. buspirone (BuSpar) and other antidepressants. Antidepressants are especially useful in patients with mixed symptomsofanxietyanddepression. c. Buspirone is a first-line treatment of GAD. d. The side effect profile for GAD patients is similar to that seen with depressive disorders. b. b. Benzodiazepines can almost always relieve anxiety if given in adequate doses. Patients who have been previously treated with benzodiazepines or who have a historyofsubstance abuse have a decreasedresponse to buspirone. 4. buttheyhave no addictivepotential and may be more effective. Tolerance tothe beneficial effects ofbuspirone does not seem to develop. There is no physiologic dependence or withdrawal syndrome. The dose should then be titrated up to a maximum dosage of 225 mg of Effexor XR per day. or who are intolerant to their side effects. Buspirone (BuSpar) a. Their onset of action is much slower than thatofthe benzodiazepines. and they have no delayed onset of action.
lightheaded or . Non-Drug Approaches to Anxiety 1. Cognitive behavioral therapy. during which four of the following symptoms begin abruptly and reach a peak within 10 minutes in the presence of intense fear: a. withthe use ofmedication ifnecessary.Awithdrawal syndrome occursin70%ofpatients. Slowtapering ofbenzodiazepines is crucial (especially those with short half-lives). C. which are almost intolerable. increased heart rate. d. Patients should stop drinking coffee and other caffeinated beverages. DSM-IV Criteria for Panic Disorder with Agoraphobia A.should then be tapered after several weeks. Patients should get adequate sleep. I. Supportive or insight oriented psychotherapy can be helpful in mild cases of anxiety. they are less likelyto result in interdose anxiety and are easier to taper. Chest pain or discomfort. Panic Disorder Patients with panic disorder report discrete periods of intense terror and fear of impending doom. Palpitations. g. f.tremulousness dysphoria. Psychotherapy a. c. 2. andavoidexcessivealcoholconsumption.characterized byintense anxiety. Both 1 and 2 are Required 1. Feeling of choking. with emphasis on relaxation techniques and instruction on misinterpretation ofphysiologic symptoms. Recurrent unexpected panic attacks occur. Drug dependency becomes a cinicalissueifthebenzodiazepine l is used regularly for more than 2-3 weeks. e. Feeling dizzy. Trembling or shaking. Since clonazepam (Klonopin) and diazepam (Valium) have long half-lives. e. d. Sensation ofshortness of breath. Benzodiazepines have few side effects other than sedation. b. b. mayimprove functioning in mild cases. Nausea or abdominal distress. Tolerance to their sedative effects develops. Sweating. 3. f. but not to their antianxiety properties. Moderate exercise each day may help reduce the intensity of anxiety symptoms. sleep and perceptual disturbancesandappetitesuppression. h.
and phobic avoidance to these situations can occur. The first panic attack often occurs without an acute stressor or warning. Clinical Features of Panic Disorder A. Panic attacks are not due to the effects of a substance or medical condition. 3. or panic in response to stimuli of a severe stressor. Agoraphobia may develop in patients with simple panic attacks. In agoraphobia. Situations are avoided or endured with marked distress. C. panic attacks may occur in relation to specific situations. III. where phobicavoidance is only limited to social situations. the most common fears are of being outside alone or of being in crowds or traveling.Epidemiology of Panic Disorder . 2. Major Depression occurs in over fifty percent of patients. At least one of the attacks has been followed by one month of one of the following: a. such as fear of having a heart attack or going crazy. i. j. l. Paresthesias. Marked anxiety about having future panic attacks (anticipatoryanxiety) is common. The anxiety is not better accounted for by another disorder. such as with post-traumatic stress disorder. Patients often believe that they have a serious medical condition. except there are no symptoms of agoraphobia. The presence of agoraphobia that has the following three components: 1. D. DSM-IV Criteria for Panic Disorder without Agoraphobia. B. A significant change in behavior related to the attacks. or these situations are endured with anxiety about developing panic symptoms. such as panic on exposure to social situations in social phobia. II. b. 2. Derealization or depersonalization. k. Fear of losing control or going crazy. Later in the disorder. B. The panic attacks are not caused by another mental disorder. C. Fear of dying. or in which help might not be available. The DSM-IV diagnostic criteria are the same as panic disorder with agoraphobia. IV. or these situations require the presence of a companion. such as social phobia. Chills or hot flushes.faint. Anxiety about being in places or situations where escape might be difficult or embarrassing. c. Elevation ofblood pressure and tachycardia may occur during a panic attack. Persistent concern about having additional attacks. m. Worry about the implications of the attack.
Classification of Panic Disorder A. pulmonary embolism and hypoxia can present with symptoms similar to panic attacks. VI.Thefemale-to-male ratio is 3:1. Substance-InducedAnxietyDisorder. B. Panic disorder usually develops in early adulthood with a peak onset in the mid twenties. may occur in up to 40% of patients. D. C. Panic disorder is characterized by discrete episodes of severe anxiety along with physiologic symptoms.5%and3.benzodiazepines or barbiturates can also precipitate panic attacks. C. The course of the illness is often chronic. Generalized AnxietyDisorder. The suicide risk is markedly increased. C. . Anxiety is more constant than in panic disorder.5%. but symptoms may wax and wane depending on the presence of stressors. such as being in a high place or in an elevator. The lifetime prevalence of panic disorder isbetween1. an individual may have panic attacks in crowded situations. especiallyin untreated patients. Pheochromocytoma may mimic panic disorder and is characterized by markedly elevated blood pressure during the episodes of anxiety. especially of alcohol. or the attack may occur only after spending a significant amount of time in a crowded location. Anxiety Due to a General Medical Condition. but he may not have an attack in every situation. Twentypercent have marked symptomatology. Cardiac arrhythmias. Situationally Predisposed Panic Attacks. Situationally Bound Panic Attacks. These panic attacks occur spontaneously without any situational trigger. but they do not necessarily occur immediatelyafter everyexposure. Unexpected Panic Attacks. Fifty percent of panic disorder patients are only mildlyaffected.Differential Diagnosis of Panic Disorder A. It is excluded by a 24-hour urine assay formetanephrineorbyserumcatecholamines.Substance abuse. Onset after age 45 years is unusual. Up to one-half of panic disorder patients have agoraphobia. Amphetamines. For example. B. First-degree relatives have an eightfold increase in panic disorder. hyperthyroidism. Physiologic withdrawalfromalcohol. V. E. These panic attacks occur immediately after exposure to the feared stimulus.A. cocaine or caffeine can mimic panic attacks. These panic attacks usually occur upon exposure to the feared stimulus. B.
7. B. . Serotonin-specific reuptake inhibitors and tricyclic antidepressants are most often used. A low dose. and it should be started at 10-25 mg per day. A long-acting agentsuch as clonazepam (Klonopin) is also effective. and increased slowly up to100-200 mg per dayas tolerated. Some patients may require up to 6 mg per day. 3. and it causes less interdose anxiety compared to alprazolam. 1.5-25 mg of sertraline (Zoloft) is used initially. The dose may then be gradually increased up to 20-40 mg for paroxetine or 50 to 100 mg for sertraline. When using a tricyclic antidepressant.VII. Treatment of Panic Disorder A. Benzodiazepines may be used adjunctively with TCAs or SSRIs during the firstfewweeks of treatment. Imipramine (Tofranil) is the best studied agent. Mild cases of panic disorder can be effectivelytreated with cognitivebehavioral psychotherapy with an emphasis onrelaxationandinstructiononmisinterpretation of physiologic symptoms. Fluoxetine (Prozac) mayexacerbate panic symptoms unless begun at very low doses (2-5 mg). the initial dose should also be low because of the potential for exacerbating panic symptoms early in treatment. The average dose is 0. 4. such as 5-10 mg of paroxetine (Paxil) or 12. When a patient has failed other agents. Alprazolam(Xanax) should be givenfour times a dayto decrease interdose anxiety. 5. SSRIs are the first-line treatment for panic disorder. Monoamine oxidase inhibitors may be the most efficacious agents available for panic disorder. 2.5 mg qid (2 mg/day). benzodiazepines are very effective. 6. but these agents are not often used because ofconcern over hypertensive crisis when patients do not follow a low tyramine diet. Buspirone (BuSpar) is not effective for panic disorder. Pharmacotherapy is indicated when patients have marked distress from panic attacks or are experiencing impairment in work or social functioning. Medication should be combined with cognitive-behavioral therapy for optimal outcome.
Situations that provoke symptoms are often avoided. the contentof thesymptoms is not restricted to the disorder (eg. such as when an individual withobsessionsofcontamination avoids touching anything that might be dirty. preoccupation with food in an eating disorder. Depression is common in patients . 3. 2. Compulsions a. The thoughts. Either Obsessions or Compulsions are present 1. The obsessions or compulsions cause marked distress. d. The disturbance is not caused by substance abuse or a medical condition. The person has recognized that the obsessions or compulsions are excessiveor unreasonable. orattempts to neutralize them with some other thought or action. for most of the current episode. or they are clearly excessive. Repetitive behaviors or acts that the person feels driven to perform in response to an obsession. If another psychiatric disorder ispresent. 6. The person attempts to ignore orsuppresssymptoms. c. Specify if the patient has poor insight into his illness. 7. leading to marked occupational and social impairment. impulses or images as a product of his or her own mind. II. 5.theperson does notrecognize the symptoms as excessive or unreasonable. or images arenot limitedtoexcessive worries about real problems. or significantly interfere with functioning. impulses. The person recognizes the thoughts. b. but they are not connected in a realistic wayto what theyare attempting to prevent. Recurrent. ClinicalFeaturesofObsessive-Compulsive Disorder A. DSM-IV CriteriaforObsessive-Compulsive Disorder A. take more than a hour a day.Obsessive-Compulsive Disorder (OCD) I. Compulsions often occupy a large portion of an individuals day.or images experienced as intrusive and causing marked anxiety. 4. B. b. Poor insight is present if. C. persistent thoughts. These behaviors or mental acts are aimed at preventing distress or preventing a specific dreaded event. impulses. Obsessions a.
Patients are reluctanttodiscuss symptoms. only5%ofOCD patients have Tourette's disorder. Body DysmorphicDisorderorTrichotillomania. hair pulling intrichotillomania). Specific or Social Phobia. Washing and checking rituals are common in children with OCD. On rare occasions a brain tumor or temporal lobe epilepsy can manifest with OCD symptoms. Generalized Anxiety Disorder. B. Substance-Induced AnxietyDisorder or AnxietyDisorderDue to a Medical Condition.with OCD. schizophrenia . obsessive rumination about finances or a relationship). Up to 50% of patients with Tourette's disorder have coexisting OCD. and these children may not consider their behavior tobe unreasonable or excessive. however. Major depression may be associated with severe obsessive ruminations (eg. D. The concordance rate for monozygotic twins is markedly higher compared to dizygotic twins. There is no sex difference in prevalence. C. obsessive worries are about real life situations. behaviors or impulses mayoccur in these disorders. Alcohol or sedative-hypnotic drug abuse is common in patients with OCD because they attempt to use the drug to reduce distress. B. Schizophrenia. obsessions usually do not involve real life situations. EpidemiologyofObsessive-Compulsive Disorder A. caffeine and other symptomatic agents may mimic the anxiety symptoms of OCD. leading to an underdiagnosis of OCD. however. E. C. in OCD. Fifteen percent of patients have a chronic debilitating course with marked impairment in social and occupational functioning. E. The lifetime prevalence of OCD is approximately 2. III. D. however. F. Amphetamines. butitmayoccasionally begin in childhood. cocaine.Patients withschizophrenia mayhave obsessivethoughtsorcompulsive behaviors. Major Depressive Disorder. D. In GAD. E.DifferentialDiagnosisofObsessive-Compulsive Disorder A. The onset is usually gradual and most patients have a chronic disease course with waxing and waning of symptoms in relation to life stressors. OCD usually begins in adolescence or earlyadulthood. These obsessive thoughts are usually not associated with compulsive behaviors and are accompanied by other symptoms of depression.5%. IV. OCDshould notbe diagnosed if symptoms are caused by another psychiatric condition (eg. Recurrent thoughts. but the age of onset is earlier in males.
and control. the fear is unrelated (eg. paroxetine (Paxil) fluoxetine (Prozac). such as fluoxetine (Prozac) 60-80 mg. Specify if the fear is generalized: The fear is generalized if the patient fears most social situations. 2. Treatment of Obsessive-Compulsive Disorder A. buthighdosesofSSRIsmaybe required. the fear is not of trembling in a patient with Parkinson's disease). and they do not believe that their behavior is abnormal. The feared situations are avoided or endured with intense distress. 3.is associated with frank hallucinations and delusions. Obsessive-Compulsive Personality Disorder (OCPD). Social Phobia I.Oftena combination of behavioral therapy and medication is most effective. sertraline (Zoloft). D. 6. The individual often fears that he will act in a way that will be humiliating or embarrassing. If a medical condition or another mental disorder is present. B. The duration of symptoms is at least six months. Standard antidepressant doses of clomipramine are usually effective. 8. Individuals with OCPDare preoccupied withperfectionism. The avoidance. Clomipramine (Anafranil). order. mayalso be effective. C. anxious anticipation. such as thought stopping. which may take the form of a panic attack. 5. desensitization or flooding. citalopram (Celexa) and fluvoxamine (Luvox) are effective. 7. 4. or sertraline (Zoloft) 200 mg. F. 9. Exposure to the feared situation almost invariably provokes anxiety. . The fear is notcaused bya substance or medical condition and is not caused by another disorder. Pharmacotherapy is almost always indicated. V. They do not exhibit obsessions or compulsions. The person recognizes that the fear is excessive or unreasonable. DSM-IV Diagnostic Criteria for Social Phobia 1. or distress in the feared situations interferes with normal functioning or causes marked distress. A marked and persistent fear of social or performance situations in which the person is exposed to unfamiliar people or to scrutiny by others. Behavior therapy. paroxetine (Paxil) 40-60 mg.
such as 10-20 mg . with a childhood history of shyness. Substance-Induced AnxietyDisorder. such as paroxetine (Paxil) 20-40 mg/day or sertraline (Zoloft) 50-100 mg/day. Treatment of Social Phobia A. then social phobia should not be diagnosed. but the disorder may remit or improve in adulthood. drinking. Epidemiology and Etiology of Social Phobia A. C. cocaine. Hyperthyroidism and other medical conditions may produce significant anxiety. difficulty being assertive. Clinical Features of Social Phobia A. or writing in public. Less common fears include fear of eating. The effective dosage can be very low. The diagnosis of social phobia should be made only if the anxiety is unrelated to another disorder. may be used if SSRIs are ineffective. Specific Phobia. Onset usually occurs in adolescence. C.Anxietysymptoms are common in depression and the anxiety disorders. Social phobia is often a lifelong problem. B. B. V.Differential Diagnosis of Social Phobia A. Anxiety Disorder Due to a General Medical Condition. Substances suchascaffeine. or of using a public restroom. Avoidance of speaking in front of groups may lead to work or school difficulties. and should be ruled out. Obsessive-Compulsive Disorder. If anxiety occurs only during the course of the mood or psychotic disorder. Social phobia is more frequent (up to tenfold) in first-degree relatives of patients with generalized social phobia. IV. while less than half fear meeting newpeople. Lifetime prevalence is 3-13%. social phobia should not be diagnosed in panic disorder if the patienthas social restriction and excessive anxiety about having an attack in public. Excessive social worry and anxiety can occur in manymood and psychotic disorders.II. SSRIs. such as propranolol.amphetamines. low self-esteem. Patients often display hypersensitivity to criticism.5 2 mg per day. B. C. Mood and Psychotic Disorders. D. Social phobia with performance anxiety responds well to beta-blockers. For example. Benzodiazepines.are the first-linemedication for social phobia. such as clonazepam (Klonopin) 0. Most patients with social phobia fear public speaking. alcohol or benzodiazepines may cause a withdrawal syndrome that can mimic symptoms of social phobia B. D. Hypochondriasis. III. orAnorexia Nervosa. and inadequate social skills.
water). Specific phobias mayresultin a significant restriction of life-activities or occupation. dogs). The phobic situation is avoided or endured with intense anxiety. . Fear of animals and other objects is common in childhood.and relaxation techniques. heights. C. Animal (eg. Blood-injection injury. H. Cognitive/behavioral therapies are effective and should focus on cognitive retraining. Vasovagal fainting is seen in 75% of patients with blood-injection injury phobias. III.desensitization. 5.qid. C. Other (eg. and specific phobia is not diagnosed unless the fear leads to significant impairment. II. anxious anticipation. Age of onset is variable. G. B. B. DSM-IV Diagnostic Criteria A. Combined pharmacotherapy and cognitive or behavioral therapies is the most effective treatment. situations that may lead to choking. Clinical Features of Specific Phobia A. Specific Phobia I. 4. The avoidance. Marked and persistent fear that is excessive or unreasonable. It may also be used on a prn basis. Specify Types of Phobias 1. C. Epidemiology of Specific Phobia A. Exposure tothe feared stimulus provokes an immediate anxiety response. Situational (eg. 3. that is caused by the presence or anticipation of a specific object or situation. Symptoms are not caused by another mental disorder (eg. Natural Environmental (eg. F. Specific phobias often occur along with other anxiety disorders. Most childhood phobias are self-limited and do not require treatment. such as unwillingness to go to school. fear of dirt in someone with OCD). The lifetime prevalence of phobias is 10%. D. which may take the form of a panic attack. elevators. storms. vomiting). In individuals under age 18. enclosed places). B. 20-40 mg given 30-60 minutes prior to the anxiety provoking event. Most do not cause clinically significant impairment or distress. D. or distress in the feared situations interferes with functioning or causes marked distress. Recognition by the patient that the fear is excessive or unreasonable. Phobias that continue into adulthood rarely remit. and females with the disorder far outnumber males. the duration must be at least six months. E. 2. airplanes.
Hyperthyroidism and other medical conditions may produce significant anxiety. combined with a relaxation technique such as deep breathing. D. Beta-blockers may also be useful prior to confronting the specific feared situation. A general state of increased arousal persists after the traumatic event. exaggerated startle response. B. Manypsychiatric disorders present with marked anxiety. B. Substancessuchascaffeine. Post-Traumatic Stress Disorder I. V. Symptoms have been present for . and the diagnosis of specific phobia should be made only if the anxiety is unrelated to another disorder. For example. reliving of the experience (flashbacks). or intense distress when exposed to reminders of the event. or irritability (two required). restricted affect. Excessive worry and anxiety occurs in many mood and psychotic disorders. amnesia. B. Anxiety Disorder Due to a General Medical Condition. Treatment of Specific Phobia A.Hypochondriasis or Anorexia Nervosa. The patient may have feelings of detachment (emotional numbing). Substance-Induced AnxietyDisorder. or active avoidance of thoughts or activities that may be reminders of the trauma (three required). hypervigilance. Post-traumatic stress disorder (PTSD) occurs after an individual has been exposed to a traumatic event that is associated with intense fear or horror. Alcohol or benzodiazepine withdrawal can also mimic phobic symptoms. consisting of gradually increasing exposure to the feared situation. The primary treatment is behavioral therapy. specific phobia should not be diagnosed in panic disorder if the patient merely has excessive anxiety about having a panic attack. whichis characterized bypoor concentration.SocialPhobia. Panic Disorder. C. DSM-IVDiagnostic CriteriaforPost-Traumatic Stress Disorder A. insomnia.IV.Obsessive-Compulsive Disorder.Differential Diagnosis of Specific Phobia A. then specific phobia should not be diagnosed. D. anhedonia. The patient persistently reexperiences the event through intrusive recollection or nightmares. A commonly used technique is systemic desensitization. C.amphetamines and cocaine can mimic phobic symptoms. Mood and Psychotic Disorders. E. If anxiety occurs only during the course of the mood or psychotic disorder.
Borderline Personality Disorder can be associated with anhedonia. Symptoms have been present for less than three months. However. Depression is notcommonlyassociated withnightmares or flashbacks of a traumatic event. II. and feelings of detachment. Survivor guilt (guilt over surviving when othershavedied)maybeexperienced if the trauma was associated with a loss of life. however. Anxiety Disorders. Depression is also associated with insomnia. Malingering.other anxietydisorders. Symptoms begin six months after the stressor. Other anxiety disorders can cause symptoms of increased arousal.Symptomshave been present for greater than three months. Personality change.poor concentration. often were present before the traumatic event. A stressful event may be associated with the onset of depression. The risk of depression. The lifetime prevalence of PTSD is 8% and is highest in young adults. With Delayed Onset. poor impulse control. C. The prevalence in combat soldiers and assault victims is 60%. B. III. Chronic.Classification of Post-Traumatic Stress Disorder A.somatization disorder. Differential Diagnosis of Post-Traumatic Stress Disorder A. and suicide are increased. D. poor concentration. Clinical Features of Post-Traumatic Stress Disorder A. substance abuse. E. EpidemiologyofPost-Traumatic Stress Disorder A. The presence of a primary financial gain for which patients may fabricate or exaggerate symptoms should be considered during evaluation. and perceptual disturbances may occur. Other features of BPD such as avoidance .dissociativesymptoms. PTSD maybe an illness for which monetary compensation is given. IV. OCD is associated with recurrent intrusive ideas. Acute. C. and avoidance. B.aggression. V. B. B. and the ideas are not usually recollections of past events. past history of emotional trauma and dissociative states similar to flashbacks. F. Symptoms cause significant distress or impaired occupational or social functioning. anhedonia. C. Obsessive-Compulsive Disorder. Symptoms.at least one month. numbing. C. these ideas lack a relationship to a specific traumatic event. Individuals with a personal history of maladaptive responses to stress may be predisposed to developing PTSD.
B. A general state of increased arousal persists after the traumatic event. Additional findings in acute stress disorder may include the following: 1. and MAO inhibitors) are moderately effective. DSM-IVCriteriaforAcute Stress Disorder. intrusive thoughts. The individual has three or more . whichischaracterizedbypoor concentration. D.of abandonment. Other SSRIs are also likely to be effective. acute phase of the illness. E. Symptoms occur within one month of a stressor and last between two days and four weeks. identity disturbance. C. reliving of the experience (flashbacks). Persistent avoidance of the traumatic event and emotional numbing (feeling of detachment from others) may be present. Acute Stress Disorder Acute stress disorder may occur as an acute reaction following exposure to extreme stress. exaggerated startle response. and impulsivity distinguishes BPD from PTSD. insomnia. VI. behavioral therapy. or active avoidance of thoughts or activities that may be reminders of the trauma (three required). The patient mayhave feelings of detachment. amitriptyline. and family therapy are effective adjuncts to pharmacological treatment. and coexisting depression. C. The patient persistentlyreexperiences the event through intrusive recollection or nightmares. B. Symptoms described below occur after an individual has been exposed to a traumatic event that is outside the realm of normal human experience (combat. support groups. anticonvulsants. hypervigilance.Treatment of Post-Traumatic Stress Disorder A.Benzodiazepines are not been effective for PTSD. Treatment at higher doses than are used for depression may be required. restricted affect. 2. or intense distress when exposed to reminders of the event. anhedonia. Propranolol. amnesia. A. Sertraline (Zoloft) and paroxetine (Paxil) have demonstrated efficacy for all the symptom clusters of PTSD. Older antidepressants (imipramine. lithium. except during the early. or irritability (two required). and buspirone may be effective and should be considered if there is no responsetoantidepressants. especially for symptoms of increased arousal. Psychotherapy. physical assault. I. natural disaster. accident).
detachmentorabsence ofemotional responsiveness. Treatment of Acute Stress Disorder A. C. Dissociative amnesia. d. II. c. Sedative hypnotics are indicated for short-term treatment of insomnia and symptoms of increased arousal. see page 121. Reductioninawarenessofsurroundings. B. Treatment of acute stress disorder consists of supportive psychotherapy. Derealization. Depersonalization. e.The clinical approach to acute stress disorder is similar to PTSD. b. The presence of acute stress disorder mayprecede PTSD.ofthe following dissociativesymptoms: a. . Antidepressantmedications are indicated if these agents are ineffective. Subjective sense of numbing. References References.
4. Personality traits consist of enduring patterns of perceiving. Patients with cluster A personality disorders often develop schizophrenia. relating to. . personality disorders are not generally diagnosed in children. The patient repeatedly questions the fidelity of his spouse or sexual partner. The patient fears that information given to others will be used maliciously against him. pervasive and maladaptive to the point where they cause significant social or occupational dysfunction or subjective distress. and is quick toreactangrilyor tocounterattack. schizotypal and schizoid personality disorders are referred to as cluster Apersonality disorders. 5. Theyareconsideredpartoftheschizophrenia-spectrum disorders. 7. C. The patientpersistentlybears grudges. harming. drug or medication effect. Patterns of behavior and perception cannot be caused by stress. Paranoid Personality Disorder I. and thinking about the environment. The patient suspects others are exploiting. Personality patterns must be stable and date back to adolescence or early adulthood. Therefore. A pervasive distrust and suspiciousness of others is present without justification. A personality disorder is diagnosed when personalitytraitsbecome inflexible. There is also an increased incidence schizophrenia in first-degree compared to the general population. Benign remarks by others or benign events are interpreted as having demeaning or threatening meanings. possiblymilder variants ofschizophrenia. another mental disorder. General Characteristics of Personality Disorders A. 6. beginning by early adulthood. 3. or deceiving him. The patient doubts the loyalty or trustworthiness of others. and is manifested by at least four of the following: 1. DSM-IV Diagnostic Criteria of Paranoid Personality Disorder A. B. other people and oneself. The patient perceives attacks that are not apparent to others. Cluster A Personality Disorders Paranoid. or a medical condition. 2. Patients usually have little or no insight into their disorder. D.Personality Disorders I. Patients with these disorders have a preference for social isolation.
Patients are often argumentative and hostile. Patients with the disorder may develop schizophrenia. including family relationships. Symptoms of anxiety and agitation may be severe enough to warrant treatment with anti-anxiety agents. PersonalityChange Due to a General MedicalConditionandSubstance-Related Disorder. beginning by early adulthood and indicated by at least four of the following: 1. Patients are quick to counterattack and are frequently involved in legal disputes. ClinicalFeatures of Paranoid Personality Disorder A. V. B. 2.Pathological jealousyis common. Fixed delusions are not seen in personality disorders.Hallucinations and formal thought disorder are not seen in personality disorder. The patient is often hypervigilant and constantly looking for proof to support his paranoia. The patient has no close friends . C. C. IV.Differential Diagnosis of Paranoid Personality Disorder A. DSM-IV Diagnostic Criteria for Schizoid Personality Disorder A. Epidemiologyof Paranoid Personality Disorder A. Apervasive pattern of social detachment with restricted affect. The disorderis more common in first-degree relatives of schizophrenics compared to the general population. 3. These patients rarely seek treatment. Patients have a high need for control and autonomy in relationships to avoid betrayal and the need to trust others. B. Delusional Disorder. III. C. Treatment of Paranoid Personality Disorder A.Acute symptoms are temporally related to a medication. The patient has little interest in having sexual experiences. The patient chooses solitaryactivities. C. but establishing and maintaining the trust of patients may be difficult because these patients have great difficulty tolerating intimacy. Low doses of antipsychotics are useful for delusional accusations and agitation. The longstanding patterns of behavior required for a personality disorder are not present. B. The disorder is more common in men than women. Schizoid Personality Disorder I.II. 5. B. The patient neither desires nor enjoys close relationships. 4. Psychotherapy is the treatment of choice for PPD. The patient takes pleasure in few activities. Paranoid Schizophrenia. drugs or a medical condition.
drugs or a medical condition. Thepatientdisplaysemotional detachment or diminished affectiveresponsiveness. which is thought to be more common in men than women. . C. Patients with schizoid personality disorder mayhave good work histories. B. E.avoidantpatients are hypersensitive to the thoughts and feelings of others. IV. Epidemiologyof Schizoid Personality Disorder A. II.or confidants except first-degree relatives. Schizoid patients are not able to express strong emotion. B. behavior and speech are not seen in schizoid personality disorder.Grouptherapyisnotrecommended because other patients will find the patient's silence difficult to tolerate. V. D. The patient often appears cold and aloof. C. Individual psychotherapyis the treatment ofchoice. 7.Differential Diagnosis of Schizoid Personality Disorder A. Eccentricities and oddities of perception. Schizophrenia. B. Avoidant Personality Disorder. B.antipsychotics andpsychostimulants has been described without consistent results. Treatment of Schizoid Personality Disorder A. whereas schizophrenic patients usually have poor work histories. Schizoid Personality Disorder is more common in first-degree relatives of schizophrenics compared to the general public.Acutesymptoms are temporally related to a medication. The patient is indifferent to the praise or criticism of others. PersonalityChange Due to a General MedicalConditionandSubstance-Related Disorder. and is uninvolved in the everyday concerns of others. Patients with Schizoid Personality Disorder may develop schizophrenia. C. 6. Hallucinations and formal thought disorder are not seen in personality disorders. Patients with SPD are often emotionally blunted. Unlike schizoid patients. Clinical Features of Schizoid Personality Disorder A. These patients are able to work if the job allows for social isolation. Paranoid patients are able to express strong emotion when theyfeel persecuted. Paranoid Personality Disorder. and these patients generally do notmarryunless pursued aggressively by another person. III. The longstanding patterns of behavior required for a personality disorder are not present. Schizoid Personality Disorder is a rare disorder. Social isolation is subjectivelyunpleasant for avoidant patients. The use ofantidepressants. Schizotypal Personality Disorder.
” illusions and derealization are common. B. Lack of close friends other than first-degree relatives. D.Differential Diagnosis of Schizotypal Personality Disorder A. 9. Discomfort in social situations. Suspiciousness or paranoid ideation. III. Unusual perceptual experiences. Patients with schizotypal personality disorder may develop schizophrenia. Ideasofreference:interpreting unrelated events as having direct reference to the patient (eg. Repeated exposure will not decrease social anxiety since it is based on l paranoidconcernsandnotonsef-consciousness. IV.perception. DSM-IV Diagnostic Criteria A. II. telepathy or a “sixth sense”). including bodily illusions. Behavior or appearance that is odd. These patients often displaypeculiarities in thinking. metaphorical.and communication of schizotypal patients. When psychosis is present in schizotypal patients.circumstantial. beginning by early adulthood. 7. belief thata television program is really about him). E.belief in “extra sensory perception. Schizoid and Avoidant Personality Disorder. No formal thought disorder is present in personality disorders. it is of brief duration. 4. Odd beliefsor magicalthinkinginconsistent withculturalnorms (eg. EpidemiologyofSchizotypalPersonality Disorder A. B. Magical thinking. belief in clairvoyance. A pervasive pattern of discomfort with and reduced capacity for close relationships as well as perceptual distortions and eccentricities of behavior.Schizotypal Personality Disorder I. . C. The patient may have a vivid fantasy life with imaginary relationships. Excessive social anxiety that does not diminish with familiarity. such as the use of unusual terminology. B. or stereotyped thinking) 5. ClinicalFeatures of Schizotypal Personality Disorder A. 3. 6. and inappropriate behavior may occur. This disorder is more common in relatives of schizophrenics compared to the general population. behavior andcommunication. 2. 8. eccentric or peculiar. At least five of the following should be present: 1. The prevalence is approximately 3% in the general population. Schizophrenia. Speech may be idiosyncratic. Oddthinkingandspeech(eg. C. Schizoid and avoidant patients will not display the oddities ofbehavior.superstitiousness. G. These patients may seek treatment for anxiety or depression. F. Inappropriate or constricted affect.
D. . paranoid patients can be very verbally aggressive and do not avoid conflict. Antidepressants may be useful if the patient also meets criteria for a mood disorder.perception and communication ofschizotypal patients.Acute symptoms are temporally related to a medication. Patients with paranoid personality disorder will not display the oddities ofbehavior. PersonalityChange Due to a General MedicalConditionandSubstance-Related Disorder. B. Psychotherapy is the treatment of choice for schizotypal personality disorder. Antipsychotics maybe helpful in dealing with low-grade psychotic symptoms or paranoid delusions. Treatment of Schizotypal Personality Disorder A.C. Unlikeschizotypals. Paranoid Personality Disorder. The longstanding patterns of behavior required for a personality disorder are not present. drugs or a medical condition. V.
APD is more common in first-degree relatives of those with the disorder. Consistent irresponsibility: repeated failure to sustain consistent work or honor financial obligations. B. stealing. substance abuse. II. The male-to-female ratio is 3:1. Since age 15 years. These disorders are characterized by dramatic or irrational behavior. 7. Adult Antisocial Behavior. Destruction of property. 6. ClinicalFeatures of AntisocialPersonality Disorder A. such as repeated physical fighting or assaults. indicated by at least three of the following: 1. the patient has exhibited disregard for and violation of the rights of others. borderline. Patients with adult antisocial behavior do not show the pervasive.Substance . These patients do not have a capacity for empathy. Substance-Related Disorder. These patients tend to be very disruptive in clinical settings. Patients may be arrogant. B. fighting. 2. physical abuse. Antisocial PersonalityDisorder I. but they are also capable of great superficial charm. III. long-term patterns required for a personality disorder. Serious violation of rules. C. Failure to conform to social norms by repeatedly engaging in unlawful activity. Lack of remorse for any of the above behavior. fraud. Epidemiologyof Antisocial Personality Disorder A. 4. IV. This diagnosis is limited to the presence of illegal behavior only. 3.Cluster B Personality Disorders Antisocial. DSM-IV Diagnostic Criteria for Antisocial Personality Disorder A. A historyof some symptoms of conduct disorder before age 15 years as indicated by: 1. and drunk driving are common. 5. Reckless disregard for the safety of self or others. 3. Lying. 2. Deceitfulness or theft.Differential Diagnosis of Antisocial Personality Disorder A. Impulsivity or failure to plan ahead. Irritability and aggressiveness. B. Aggression to people and animals. Interactions with others are typically exploitative or abusive. histrionic and narcissistic personality disorders are referred to as cluster B personalitydisorders. Deceitfulness: repeated lying or “conning” others for profit or pleasure. D. B. 4.
These patients will try to destroy or avoid the therapeutic relationship. 4. 2. Identity disturbance: unstable self-image or sense of self. DSM-IV Diagnostic Criteria for Borderline Personality Disorder Apervasivepattern ofunstable interpersonal relationships. intense anger .Antidepressants can be helpful if depression or an anxiety disorder is present. irritability or anxiety of short duration). unstable self-image. and indicated by at least five of the following: 1.unstable affects. 3. Unstable and intense interpersonal relationships. and poor impulse control. reckless driving. Borderline Personality Disorder. and because enhanced peer interaction minimizes authority issues. alternating between extremes of idealization and devaluation. 6. sudden intense dysphoria. B. Frantic efforts to avoid real or imagined abandonment. but they are not as aggressive or deceitful as antisocial patients. lithium. Borderline Personality Disorder I. Affective instability (eg. binge eating). D. Psychotropic medication is used in patients whose symptoms interfere with functioning or who meet criteria t foranotherpsychiatricdisorder. C. The manipulativeness of borderline patients is aimed at getting emotional gratification rather than aimed at financial motivations. and beta-blockers have been used for impulse control problems.Aniconvulsants. 8. Inpatient self-help groups are the most useful treatment because the patient is not allowed to leave. Many patients will meet criteria for both diagnoses. but they are more emotionally unstable and they are less aggressive. V.beginning by early adulthood.orself-mutilating behavior. Chronic feelings of emptiness.abuse iscommon inantisocialpersonality disorder. including rage reactions. Recurrent suicidal behavior. 7. and crimes may be committed to obtain drugs or to obtain money for drugs. promiscuity. Narcissistic patients also lack empathy and are exploitative.substance abuse. Treatment of Antisocial Personality Disorder A. Impulsivity in at least two areas that are potentiallyself-damaging (eg. These patients are also impulsive and manipulative. Inappropriate. Narcissistic Personality Disorder.spending. gestures or threats. 5.
IV. .anddesperate dependence on others is caused by inability to tolerate being alone. ClinicalFeaturesofBorderlinePersonality Disorder A. Epidemiologyof Borderline Personality Disorder A. eating disorders. and anxiety disorders. PersonalityChange Due toaGeneral MedicalConditionandSubstance-Related Disorder. but they do not display self-destructiveness and rage. Patients frequently try to recreate their personal chaos in treatment by displaying acting-out behavior. C. 9. When faced with abandonment. drugs. Achildhood historyof abuse or parental neglect is common. stress-related paranoid ideation. and self-destructive orself-mutilatorybehavior is common. Suicide threats and attempts are common. Psychosis and dissociation are not typically seen in histrionic patients. Normal adolescence with identitydisturbance and emotional lability shares many of the same characteristics of BPD. Psychotherapy is the treatment of choice. dependent patients will increase their submissive behavior rather than display rage as do borderline patients. or a medical condition. The disorderisfivetimes more common in first-degree relatives. Treatment of Borderline Personality Disorder A. but the disorder occurs in 30-60%ofpsychiatric patients. resistance to treatment. The clinical presentation of BPD is highly variable.II. or severe dissociative symptoms. Dependent Personality Disorder. Chaotic interpersonal relationships are characteristic. The prevalence is 1-2%. The female-to-male ratio is 2:1.and regression. C. V. C. labilityof mood and affect. Differential Diagnosis of Borderline Personality Disorder A. B. Histrionic Personality Disorder. Transient. B. B. Adolescence. B. or difficulty controlling anger. These patients are also manipulative and attention seeking. Pharmacotherapy is frequently used for coexisting mood disorders. however. Acute symptoms are temporally related to medications. III. Chronic dysphoria is common. D. Valproate (Depakote) or SSRIs maybe helpful for impulsive-aggressive behavior. the longstanding pervasive pattern of behavior required for a personality disorder is not present.
t t impulsive. Differential Diagnosis of Histrionic Personality Disorder A. but does notfinish them (including relationships). Dramatic emotional “performances” of the patient appear to lack sincerity. superficially charming. The patient begins projects. A pervasive pattern of excessive emotionality and attention seeking.manipulation. Anisocialpatientsarealsosensaion-seeking. somatization and conversion disorder compared to the general population. 2. . 8. The patient may resort to suicidal gestures and threats to get attention. The patient consistently uses physical appearance to attract attention. as indicated byfive or more ofthe following: 1. Some patients meet criteria for both BPD and HPD. Borderline Personality Disorder 1. 5. B. The patient is often inappropriately sexually seductive or provocative with others. they also have identity disturbance. Dramatic. impulsive. and manipulative. IV. Antisocial Personality Disorder 1. 2. The patient is easily influenced by others or by circumstances. Histrionic personality disorder is much more common in women than men. and dissociation which are not seen in histrionic patients. These patients have higher rates of depression. transient psychosis. While patients with Borderline Personalitycanalsobesensation-seeking. Relationships are considered to be more intimate than they are in reality. D. 3. Speechisexcessivelyimpressionistic and lacking in detail. C. ClinicalFeatures of Histrionic Personality Disorder A. or dependency. EpidemiologyofHistrionic Personality Disorder A. 6. The patient is bored with routine and dislikes delays in gratification. beginning by early adulthood. 4. These patients often attempt to control relationshipswithseduction. superficiallycharming. and manipulative. B. 7. II. Histrionic patients are dramatic and theatrical but typically lack histories of antisocial behavior.Histrionic Personality Disorder I. III.and exaggerated expression of emotion is used.theatrical. DSM-IV Diagnostic Criteria A. The prevalence of HPD is 2-3%. E. 2. The patient is not comfortable unless he is the center of attention. C. Rapidlyshifting and shallowexpression of emotions are present. B.
Antidepressants are used ifdepression is also present. Lacks empathy.Acute symptoms are temporaly related to medication. The disorder begins byearlyadulthood and is indicated by at least five of the following: 1. Their inflated sense of self results in a devaluation of others and their accomplishments. 2. Treatment of Histrionic Personality Disorder A. 5. Requires excessive admiration. Insight-oriented psychotherapy is the treatment of choice. Narcissistic Personality Disorder I. but it must be positive in order to confirm grandiosity and superiority. or ideal love. Preoccupation with fantasies of unlimited success. 4. 7. D. Believes he is “special” and can only be understood by. 8. Keeping patients in therapycan be challenging since these patients dislike routine. 6. These patients feel very entitled. Narcissistic Personality Disorder 1. II. DSM-IV Diagnostic Criteria A. and lack of empathy. C. B. or a medical condition. brilliance. Histrionics are less selective and will readily appear weak and dependent in order to get attention. ClinicalFeatures of NarcissisticPersonality Disorder A. haughtybehavior or attitudes. 2. other special or high-status people (or institutions). and they are surprised when theydo not receive the recognition they expect.C. need for admiration. A pervasive pattern of grandiosity (in fantasy or behavior). expecting others to meet their needs immediately. drugs. and they can become quite indignant ifthis does not happen. Narcissists also seek constant attention. These patients are self-absorbed . Narcissistic patients only pursue relationships that will benefit them in some way. Patients with narcissistic personality disorder exaggerate their achievements and talents. Has a sense of entitlement. Shows arrogant. Anexaggeratedsenseofself-importance. 9. The patient is often envious of others or believes that others are envious of him. beauty. PersonalityChange DuetoaGeneral MedicalConditionandSubstance-Related l Disorder. power. Takes advantage of others to achieve his own ends. B. 3. V. or should associate with.
Psychotherapy is the treatment of choice. skill or belongings that they do not possess. B. Histrionic Personality Disorder. B. The prevalence of NPD is less than 1% in the general population and up to 16% in clinical populations. These patients also tend to idealize and devalue others. and lack of empathy can be seen in both antisocial personality disorder and narcissistic personality disorder.butthe therapeutic relationship can be difficult since envy often becomes an issue. Any perception of criticism is poorly tolerated. They aremorehighlyemotional and seductive compared to patients with NPD.andabandonment fears that characterize borderline patients. antidepressants are useful for adjunctive therapy. Treatment of Narcissistic Personality Disorder A. Antisocial Personality Disorder. Histrionic patients are also attention seeking. EpidemiologyofNarcissisticPersonality Disorder A. antisocial patients do not require constant admiration nor do they display the envy seen in narcissistic patients. The disorder is more common in men than women. D. These patients are very prone to envyanyone who possesses knowledge. Differential Diagnosis of Narcissistic Personality Disorder A. Much of narcissistic behavior serves as a defense against very poor self-esteem. V. . drugs or a medical condition. Borderline Personality Disorder. Interpersonal exploitation. B.therefore. superficial charm. However. C. Coexisting substance abuse may complicate treatment. III. IV. Studies have shown a steadyincrease in the incidence of narcissistic personality disorder. self-destructivebehavior. and these patients can react with rage. D. PersonalityChangeDuetoaGeneral MedicalConditionandSubstance-Related Disorder. but narcissistic patients lack the unstable identity. but the attention they seek does not need to be admiring.and unable to respond to the needs of others.All symptoms are temporally related to medication. Depression frequentlycoexists with NPD.
unappealing or inferior to others. Restrained in intimate relationships due to fear of being shamed or ridiculed. The two disorders mayonlybe differentiated by a life-long pattern of avoidance seen in patients with avoidantpersonality . disapproval or rejection. These patients are often devastated by minor comments they perceive to be critical. Opportunities to supervise others at work are usually avoided by the patient. avoidant personality disorder patients usually long to be accepted and be more social. B. C. 7.Cluster C Personality Disorders Avoidant. Although adultswithavoidantpersonality disorder were frequentlyshyas children. 2. Unwilling to get involved with people unless certain of being liked. 3. The patient is usually shy and quiet and prefers to be alone. 5. The patient usually anticipates unwarranted rejection before it happens. beginning byearlyadulthood. The patient avoids occupational activities withsignificantinterpersonal contact due to fear of criticism. B. Differential Diagnosis of Avoidant Personality Disorder A. DSM-IV Diagnostic Criteria A pervasive pattern of social inhibition. childhood shyness is notapredisposing factor. The male-to-female ratio is 1:1. These patients tend to be anxious and their personality pathology is a maladaptive attempt to control anxiety. 6. Social Phobia. Despite self-imposed restrictions. The patient views himself as socially inept. Preoccupied with being criticized or rejected in social situations. Reluctance to take personal risks or to engage in new activities because theymaybe embarrassing. Avoidant Personality Disorder I. dependent and obsessive-compulsive personality disorders are referred to as cluster C personalitydisorders. IV. II. 4. Clinical Features of Avoidant Personality Disorder A. Inhibited in new interpersonal situations due tofeelings ofinadequacy. Patients may meet criteria for both disorders. feelings of inadequacyand hypersensitivity. Epidemiologyof Avoidant Personality Disorder A. Generalized Type shares many features of avoidant personality disorder. and indicated by at least four of the following: 1. III.
Treatment of Avoidant Personality Disorder A. Group therapy may assist in dealing with social anxiety. but they will risk humiliation and rejection in order to get theirdependent needs met. and fears of separation beginning byearlyadulthood and indicated by at least five of the following: 1. Difficultyexpressing disagreement with others and unrealistically fears loss of support or approval if he disagrees. These patients also avoid interactions with others and are anxious in social settings. Difficulty initiating projects or doing things on his or her own because of a lack ofself-confidence in judgment or abilities. and these disorders should be treated with antidepressants or anxiolytics. to the point of volunteering to do things that are unpleasant. a trial of SSRI medication mayprove beneficial. 4. schizoid patients do not fear criticism and rejection. Beta-blockers can be useful for situational anxiety. Patients are prone to other mood and anxiety disorders. Patients may meet the criteria for both disorders. Avoidant patients recognize that social isolation is abnormal. V.disorder. D. C. group psychotherapyand behavioraltechniques may all be useful. Schizoid Personality Disorder. Since many of these patients will meetcriteria forSocialPhobia (generalized). Difficultymaking everydaydecisions without excessive advice and reassurance. may help the patient to overcome anxiety and shyness. B. however. In patients with panic disorder with agoraphobia. Dependent Personality Disorder I. clinging behavior. Needsotherstoassumeresponsibility for major areas of his life. 3. Panic Disorder with Agoraphobia. B. Individual psychotherapy.This need leads tosubmissive. 2. Dependent Personality Disorder. such as assertiveness training and systematic desensitization. Behavioral techniques. These patients are also hypersensitive to criticism and crave acceptance. . C. and the avoidanceisaimed atpreventing another panic attack from occurring. Goes to excessive lengths to obtain nurturance and support. 5. DSM-IV Diagnostic Criteria A pervasive and excessive need to be cared for. avoidance occurs after the panic attack has begun.
IV. B. III. B. Patients will endure great discomfort in order to perpetuate the caretaking relationship. 7. B. V. D. Childhood illness or separation anxiety disorder of childhood predispose patients to dependent personality disorder. EpidemiologyofDependentPersonality Disorders A. Borderline Personality Disorder: Borderline patients react with rage and emptinesswhen feeling abandoned.Theytend tobeveryflamboyant.II. group. Dependent patients react with more submissive behavior when feeling abandoned. Some patients may meet criteria for both disorders. Dependent patients are at increased risk for mood disorders and anxiety disorders. but these patients actively pursue almost any kind of attention. drugs or a medical condition. Social interaction is usuallylimited to the caretaker network. Family therapy may also be helpful in supporting new needs of the dependent patient in treatment.Appropriate pharmacological interventions may be used if the patient has these disorders. Avoidant Personality Disorder: Avoidant patients are more focused on avoiding shame and rejection rather than getting needs met. PersonalityChange Due toa General MedicalConditionandSubstance-Related Disorder:Acute symptoms are temporally related to a medication. 8. These patients may function at work if no initiative is required. 6. unlike dependent patients. and behavioral therapies. . and they have a strong desire for approval. Treatment of Dependent Personality Disorders A. Unrealistically preoccupied with fears of being left to take care of himself. such as assertiveness and social skills training .have all been used with success. Histrionic Personality Disorder. Uncomfortable or helpless when alone due to exaggerated fears of being unable to care for himself. Urgently seeks another source of care and support when a close relationship ends. Differential Diagnosis of Dependent Personality Disorders A. Women are affected slightly more than men. C. B. ClinicalFeatures ofDependentPersonality Disorders A. These patients are also needy and clinging. Insight-oriented psychotherapy.
Obsessive-Compulsive Disorder (OCD). openness. Obsessive-compulsive personality disorder is more frequent in first degree relatives. Tasks may be difficult to complete. Excessively devoted to work and productivity to the exclusion of leisure activities and friendships. These patients prefer logic and intellect to feelings. organization or schedules. 4. at the expense of flexibility. V. to the extent that the major point of the activity is lost. beginning by early adulthood and indicated by at least four of the following: 1. C. These patients are often very“frugal” with regard to financial matters.although the two conditions can coexist.Obsessive-CompulsivePersonality Disorder I. 2. .Long-term. lists. 8. The longstanding patterns of behavior required for a personalitydisorder are not present. Overconscieniousness.individual therapy is usually helpful. EpidemiologyofObsessive-Compulsive Personality Disorder A. drugs. C.scrupulousness t and inflexibility about morality. and efficiency. PersonalityChange Due to a General MedicalConditionandSubstance-Related Disorder. DifferentialDiagnosisofObsessive-Compulsive Personality Disorder A. or a medical condition. 3. and they are not able to be openly affectionate. DSM-IV Diagnostic Criteria A. Preoccupied with details. rules. ethics. IV. Rigidity and stubbornness. 6. Most patients with OCD do notmeetcriteriaforOCPD. Perfectionism interferes with task completion. Reluctant to delegate tasks to others. ClinicalFeatures ofObsessive-Compulsive Personality Disorder A. Unable to discard worn-out or worthless objects.Acute symptoms are temporally related to a medication. B. even if they have no sentimental value. The male-to-female ratio is 2:1. B. Obsession with detail can paralyze decision making. Therapy can II. Miserly spending style toward both self and others. A pervasive pattern of preoccupation with orderliness. III. or values (not accounted for by culture or religion). B. The prevalence of OCPD is 1% in the general population and up to 10% in clinical populations. 5. Treatment of Obsessive-Compulsive PersonalityDisorder. perfectionism and control. 7.
see page 121. References References.be difficult due to the patient’s limited insight and rigidity. .
Frequently encountered symptoms include nausea. The disorder often begins during adolescence. and patients frequently seek medical treatment or pursue multiple concurrenttreatments.Differential Diagnosis of Somatization Disorder A. History of pain related to at least four sites or functions. IV.ThefrequencyofSomatization Disorder is inversely related to social class. D. Factitious Disorder. must be excluded. Mood and anxietydisorders and substance-related disorders are common in somatization disorder. The frequencyand severityof symptoms may vary with level of stress. Fifteen percent of patients have a positive familyhistory. Two-thirds of patients have coexisting psychiatric diagnoses. Onset is before the age of 30.and pregnancy or menstruation associated complaints. 2. C. B.1 to 0. Two GI symptoms. D. such as systemic lupus erythematosus. C. III. The lifetime prevalence is 0. 4.shortness ofbreath.SomatoformandFactitious Disorders Somatization Disorder I. Malingering is suspected when there are external motives (eg. One sexual symptom. extremity pain. Physical Complaints 1. Many physical complaints. EpidemiologyofSomatization Disorder A.5%. resulting in treatment being sought or significant functional impairment. DSM-IV Criteria A. C. and hospitalizations. D. In factitious . Somatization disorder is a chronic problem. Onesymptom suggestiveofa neurological condition (pseudoneurological). vomiting. B. Symptoms cannot be explained by organic etiology or symptoms are in excess of what is expected from the medical evaluation. Patients undergo multiple procedures. 3.and theconcordance rate is higher in monozygotic twins. The disorder is 5-20 times more prevalent inwomen. Clinical Features of Somatization Disorder A. and schizophrenia. financial) that would be furthered bythe intentional production of symptoms. surgeries. Medical conditions that present varied symptoms. Prominent somatic complaints can also be associated with depression. B. anxiety. B. II. Symptoms are notintentionallyproduced.HIVor multiple sclerosis.
III. and pseudoseizures. Symptoms result in significant functional impairment. Patients often lack the characteristic normal concern about the deficit. Abnormalities usually do not have a normal anatomical distribution and the neurological exam is normal. Psychotherapy is beneficial to help the patient find more appropriate and direct ways of expressing their emotional needs.disorder symptoms are intentionally produced to assume the sick role to meet a psychological need. B. The patient should have a primary care physician and should be seen at regular intervals tominimizeinappropriate use of medical services. B. Epidemiologyof Conversion Disorder A. and schizophrenia. IV. The temporal relation of symptoms to a stressful event suggests association of psychological factors. and are not explained by another mental disorder. C.Differential Diagnosis of Conversion Disorder A. Symptoms are notintentionallyproduced. D. The most common symptoms are sensory (blindness. B. Conversion symptoms often will temporarily remit after the disorder has been suggested by the physician. Medical conditions must be excluded. anxiety disorders. C. B.” Conversion disorder can coexist with depression. II. mutism). D. The patient complains of symptoms or deficits affecting voluntary muscles.000 in the general population and in up to 3% of outpatient psychiatric patients. . E. DSM-IV Criteria for Conversion Disorder A. Treatment of Somatization Disorder A. Symptoms are not limited to pain or sexual dysfunction. urinaryretention. F. Symptoms are not explained by an organic etiology. numbness) and motor deficits (paralysis. Behaviorally oriented group therapy is also helpful. or deficits of sensory function that suggest a neurological or medical condition. Deficits tend to change over time. Conversion disorder occursin1-30/10. V. torticollis and voluntary motor paralysis (astasia-abasia). ClinicalFeatures of Conversion Disorder A. Other symptoms include pseudocyesis (pregnancy). The physical complaints that occur insomatization disorder are an expression of emotional issues. Conversion Disorder I. This characteristic lack of concern has been termed “la belle indifference. The disorder is more common in lower socioeconomic groups.
the patient is not reassured. Symptoms are not related to delusions or restricted to specific concern about appearance. Symptoms are not accounted for by another mental disorder. Anxiolytics and relaxation may also be helpful in some cases. II. Somatization Disorder begins in early life and involves multi-organ symptoms. D. B. and complaintsare often vague and ambiguous. DSM-IV Criteria for Hypochondriasis A. Major depression. and they are intentionally created to assume a sick role. The disorder results in significant functional impairment. E. B. B. The patient is not reassured by a negative medical evaluation. Treatment of Conversion Disorder A. IV. diagnostic or laboratory evaluation. Factitious Disorder. Supportive. Hypochondriasis “with poor insight” is present if the patient fails to recognize that his concern abouthealth is excessive or unreasonable. D. symptoms are not consciously produced. III. Epidemiology and Classification of Hypochondriasis A. Duration is greater than six months. Repeated diagnostic procedures mayresult in unrelated medical complications. The prevalence ranges from 4-9%. Malingering is characterized by the presence of external motivations behind fabrication of symptoms. The physician should avoid confrontation or focusing on the symptoms. Despite clinical. Preoccupation with fear of having a serious disease. C. Patients tend to be very concerned about symptoms. Symptoms are under conscious voluntary control. V. and there is no sex predominance. B.B.obsessive-compulsive disorder.based on misinterpretation of symptoms. Clinical Features of Hypochondriasis A. F. Hypochondriasis I.DifferentialDiagnosis of Hypochondriasis A. B. In conversion disorder. and panic disorder can often cause prominent somatic complaints with no organic basis. C. Benzodiazepines can be useful when anxiety symptoms are prominent. Doctor shopping is common. generalized anxiety disorder. Symptoms typically last for days to weeks and typicallyremit spontaneously.insight-oriented orbehavioral therapy can facilitate recovery. Medical conditions that can produce . The focus should be on psychological issues and any secondary gain. Hypochondriasis is most frequent between age 20 to 30 years.
F. E. as opposed to fear of having a disease in hypochondriasis. IV. B. multiple sclerosis. and it may be related to stressful life events. II. V. in contrast to the fear of having an illness that occurs in hypochondriasis. must be excluded. Factitious Disorder and Malingering.DifferentialDiagnosis of BodyDysmorphic Disorder A. A preoccupation with imagined defect in appearance. and body build are the most frequently “defective” features. D. Multiple visits to surgeons and dermatologists are common. The preoccupation causes significant functional impairment. hair. Improvement usually results from reassurance through regular physician visits. Cognitive-behavioral group therapy. B. Concerns about the imagined defect mayreach delusional proportions without meeting criteria for a psychotic disorder. Treatment of Hypochondriasis A. This disorder tends to cause only one symptom. and it can be mistaken for dysmorphic disorder. Hypochondriasis is sometimes episodic. B.Concerns are limited onlyto physical appearance. Hypochondriacal patients realistically experience the symptoms and do not fabricate them. DSM-IV Criteria for Body Dysmorphic Disorder A. Preoccupation aboutbodyimage are limited toconcerns . The focus of the patient is on the symptoms. C. There is preliminary evidence that SSRI medications are beneficial. B.varied symptoms. is most helpful. and the patient has less concern about the symptom. Epidemiologyof Dysmorphic Disorder A. C. Neurological “neglect” is seen in parietal lobe lesions. III. Body Dysmorphic Disorder I. ClinicalFeatures of Dysmorphic Disorder A. Coexisting psychiatric conditions should be treated. Somatization Disorder. Anorexia Nervosa. Facial features. such as AIDS. rather than individual therapy. Major depressive disorder and anxiety disorders frequently coexist with body dysmorphic disorder. with women affected as frequently as men. and systemic lupus erythematosus. Preoccupation is not caused for by another mental disorder. BodyDysmorphic Disorder. The disorder is most common between the ages of 15 and 20 years. Familyhistoryreflects a higher incidence of mood disordersand obsessive-compulsive disorder (OCD). B. Conversion Disorder.
B. Patients with physical symptoms often have histories of many surgeries and hospitalizations.Characterized by discomfort with the patient’s own sex and persistent identification with the opposite sex. B. Surgical repair of the “defect” is rarely successful.Coexistingpsychiatric conditions. C. Narcissistic Personality Disorder. More frequent in men and among health-care workers. Begins in early adulthood. concern with a body partis onlyone feature in broad constelation l of other personality features. This is considered to be a form of child abuse. The patients motivation is to assume the sick role.about being “fat. Identity disturbance and dependent and narcissistic traits are frequent. V. Clinical Features of Factitious Disorder A. Great effort should be made to confirm the facts presented by the patient and confirm the past medical history.” C. Gender IdentityDisorder. C. With predominantly psychological signs and symptoms. III. V. IV. With predominantly physical signs andsymptoms(alsoknownasMunchausen Syndrome). SSRI antidepressants and clomipramine are effective. An outside informant should be sought to provide corroborating information. Factitious disorder byproxyischaracterized bythe production of feigning of physical signs or symptoms in another person who is under the person’s care (typically a child). B. C. should be treated. Differential Diagnosis A. . use of drugs such as insulin. such as a mood disorders. D. B. Factitious Disorder I. In this disorder. Patients are able to provide a detailed history and describe symptoms of a particular disease and mayintentionally produce symptoms (eg. Symptomsare notfabricated. Classification of Factitious Disorder A. Epidemiology of Factitious Disorder A. Somatoform Disorders: Somatoform disorder patients are less willing to undergo medical procedures. With combined psychological and physical symptoms. Common coexisting psychological symptoms include depression or factitious psychosis. External motives (financial gain) are absent. such as surgery. II. self-inoculation to produce abscesses). Intentional production of physical or psychological symptoms. DSM-IV Criteria A. D. Treatment Bodyof Dysmorphic Disorder.
see page 121.and needless medical procedures should be prevented. Malingering: A recognizable goal for producing symptoms is present.B. C. . No specific treatment exists. and the prognosis is generally poor.Close collaboration between the medical staff and psychiatrist is recommended. B. The condition should be recognized early. Treatment of Factitious Disorder A. Ganser’s syndromerefers toa condition associated with prison inmates who give ridiculous answers to questions (1+ 1= 5)inaneffort toavoid responsibility for their actions. VI. References References.
B. C. The disorder is not due to the effects of medication. B. Zaleplon (Sonata) is a benzodiazepine receptor agonist that is rapidlyabsorbed (Tmax = 1 hour) and has a shortelimination half-life of one hour. headaches. Many medical conditions can cause insomnia including asthma. I. gastritis. DSM-IV Criteria A. C. E. or a medical condition. Manydrugs can disrupt sleep including beta-blockers. B. Differential Diagnosis A. resulting in significant distress or impairment. Treatment A. stimulating antidepressants. peptic ulcer disease. Dyssomnias. steroids. Mood disorders account for less than 50% of insomnia. The disorder causes significant distress or impairment in social or occupational functioning. Zolpidem is associated with greater residual impairment in memory and psychomotorperformance than zaleplon. Schizophrenia is associated with fragmented sleep. nicotine. C. substance abuse. drugs of abuse. C. Zaleplon does not cause residual . The safety profile of benzodiazepines and benzodiazepine receptor agonists is good. D. calcium channel blockers. Temporaryuse (less than one month) of short-acting benzodiazepines is especially helpful when there is an identifiable precipitant (eg. lethal overdose is rare. Anxiety or depression commonly coexist with insomnia. B. except when benzodiazepines are taken with alcohol. death of a loved one). Zaleplon does not impair memory or psychomotor functioning on morning awakening. or psychotic disorders may present with insomnia. III. mood. Clinical Features A. Zolpidem (Ambien) and zaleplon (Sonata) have the advantageofachieving hypnotic effects with less tolerance and less daytime sedation. IV. II. Difficulty initiating or maintaining sleep when there is no known physical or mental condition (including drug related). thyroid hormones. and bronchodilators. decongestants. Zolpidem (Ambien)is a benzodiazepine agonist with a short elimination half-life that is effective in inducing sleep onset and promoting sleep maintenance. anxiety.Sleep Disorders Primary Insomnia Primary insomnia is characterized by the inability to initiate or maintain sleep.
2. Avoid daytime naps. It can be used at bedtime or after the patient has tried to fall asleep naturally. 6. Encourage patient to keep a consistent pattern of waking. Sedating antidepressantsare sometimes used as analternativetobenzodiazepines or benzodiazepine receptor agonists. G. some patients can experience perceptual disturbances Zalepl on (Sonata) 5 -10 mg 1 hour Triazo lam (Halci on) 0. may be effective in promoting sleep onset and sustaining sleep. Allow for a period of relaxation before bedtime (hot bath). Avoid large meals before bedtime. Agents Used for Insomnia Agent Dosage Ave Halflife of Meta bolite s 3 hours Comments Zolpid em (Ambi en) 5-10 mg qhs Nonbenzodiazepine . 4. Discontinue stimulant caffeine. such as flurazepam (Dalmane).25 mg qhs 2 hours . These drugs tend to accumulate and have effects that extend beyond the desired sleep period. 3.impairment when the drug is taken in the middle of the night. no daytime hangover Nonbenzodiazepine . and sleeping at the same time each day. 25-50 mg at bedtime. 5. Sleep Hygiene: 1. or trazodone (Desyrel).12 50. F. resulting in daytime sedation or functional impairment. 50-100 mg. but avoid exercise before sleeping. Amitriptyline (Elavil). no daytime hangover Short acting. Engage in regular exercise. H. are common choices. or nicotine. Benzodiazepines with long half-lives. alcohol.
anxiety. Clinical Features A. DSM-IV Criteria for PrimaryHypersomnia A. The disorder is not due to the effects of medication. Can be associated with autonomic dysfunction. II. B.Treatment. Substance abuse.5 30 mg qhs 15-30 mg qhs 11 hours Short act ing 100 hours. active metab olites long t ½ Hangover is com mon. D. are useful. Tricyc lic Antidepress ants Doxep in (Sineq uan) Antihi stami nes Diphe nhydr amine (Bena dryl) 50100 mg Long Anticholin ergic side effects 50 mg NA Limited efficacy for mild initial insomnia. Sleep architecture is normal. IV. B. C. mood. May be familial. drugs of abuse. Depression often coexists. given in the morning. B.For daytime sleepiness stimulants such as amphetamine or methylphenidate (Ritalin). Differential Diagnosis A. Modafinil (Provigil) is a non-amphetamine stimulantapprovedfor treatmentofexcessive . or a medical condition. Can accumu late in elderly. Primary Hypersomnia I.Tema zepa m (Resto ril) Fluraz epam (Dalm ane) 7. The disorder causes significant distress or impairment in social or occupational functioning. C. or psychotic disorders may present with hypersomnia. III. Excessive somnolence occurs for one month in the absence of physical or medical condition and is associated with daytime sleepiness. Atypicaldepression and thedepressed phase of bipolar illness may present withhypersomnia as an isolated symptom.
The disorder causes significant distress or impairment in social or occupational functioning. poor concentration. The disorder is not due to the effects of medication. Narcolepsy I. depression) or to the effect of drugs of abuse. IV. Social reticence occurs due to fear of having sleep attack. Sleep apnea is associated with snoring. substance abuse. DifferentialDiagnosis: Sleep deprivation. and generalized anxiety disorder. Breathing-Related Sleep Disorder (Sleep Apnea) I. or a medical condition. drugs of abuse. III. substance abuse. DSM-IV Criteria for Narcolepsy A. C. such as depression. II. restless sleep. Sleep disruption leading to daytime sleepiness due to a sleep-related condition. Modafinil is effective at a dosage of 200 mg given in the morning. sleep paralysis. Maybe familial (>90% have HLA-DR2). are sometimes combined with tricyclic antidepressants (Protriptyline10-20 mg) before bedtime. II. The disturbance is not due to another mental disorder (eg. or a medical condition. B. DSM-IV Criteria for Breathing-Related Sleep Disorder A. hypersomnia associated with mental disorder. primary hypersomnia. C. 10 mg bid or tid. breathing-related disorders. Sleep attacks with abnormal manifestations of rapid eye movement sleep during the day(hallucinations. Clinical Features A. and anxiety disorders. C. Modafinil (Provigil) is a non-amphetamine stimulantapproved for treatmentof excessive daytimesleepiness associated withnarcolepsy. The disorder causes significant distress or impairment in social or occupational functioning. D. C. Nocturnalpolysomnographydemonstrates apneic episodes. Clinical Features A. Apnea can be central due to brain . Sudden onset of sleep (cataplexy) can be triggered by strong emotions. and decreased slow wave and rapid eye movement sleep.Treatment:Stimulants. medication or general medical condition such as arthritis. Narcolepsy is often associated with mood disorders. cataplexy). frequent arousals.daytime sleepiness associated withnarcolepsy. B. depression. B. sleep onset REM. memory disturbance. Excessive daytime sleepiness. B. Modafinil is effective at a dosage of 200 mg given in the morning.such as methylphenidate (Ritalin).
Treatment A. . Common in elderly (40%).and uvuloplasty are also indicated if theyare contributing to the apnea. IV. which can occur with jet lag or shift work. performance can be impaired during wakefulness. The disorder is not due to the effects of medication. Standard treatments include L-dopa and benzodiazepines. Weightloss. Restless Legs Syndrome A. The disorder causes significant distress or impairment in social or occupational functioning. The body naturally adapts to time shifts within one week. Nocturnal Myoclonus (periodic leg movements) A. Common in middle age (5%). B. D.stem dysfunction or obstructive due to airway obstruction. B. B. opioids or carbamazepine can be helpful. Circadian Rhythm Sleep Disorder I. Abrupt contractions of leg muscles. B. DSM-IV Criteria for Circadian Rhythm Sleep Disorder A. III. Misalignment between desired and actual sleep periods. Dyssomnias Not Otherwise Specified I. Mood disorders such as depression and mania can be precipitated by sleep deprivation. medical conditions and substance abuse or withdrawalmaycause sleep disturbances. or a medical condition. Painful or uncomfortable sensations in calves when sitting or lying down.nasal surgery. C. C. drugs of abuse. DifferentialDiagnosis: Other Dyssomnias. B. III. Nasal continuous positive airway pressure (NCPAP) is the treatment of choice.propranolol. Clinical Features A.benzodiazepines. or can be idiopathic.Treatment A. B. With jet lag and shift work. Obstructive sleep apnea is the most common type. II. Results in frequentarousals and daytime somnolence. Massage. C. Zolpidem (Ambien) or triazolam (Halcion) can be used to correct sleep pattern. II.
Substance use during hazardous activities.Failure to meet work. 2. using. or a decreased effect results when the same amount is used. suchasmood lability. II. Substance Dependence A.or recreational activities.Substance use resultsinadecreased amount of time spent in social. 4. III. Significant maladaptive. 4. and impaired social or occupational functioning due to ingestion of the substance. 3. school. and the presence of three of the following in a 12-month period: 1.impaired judgement. behavioral or psychological changes occur.Substance Abuse Disorders Substance-Related Disorders DSM-IV Diagnostic Criteria Substance-Related Disorders I. Substance Intoxication A. or home obligations.The patient has knowledge that the substance use is detrimental to his health.A significant amount of time is spent obtaining.The substance is used in increasingly larger amounts or over a longer period of time than desired.Recurrent substance-related legal problems. 3. Substance use has not met criteria for dependence. 2.buthas lead toimpairment or distress as indicated by at least one of the following during a 12-month period: 1. Substance Abuse A.Continued use of the substance despite continued social problems. occupational. 6. 7. or recovering from the substance. accompanied by impairment.Tolerance: An increased amount of substance is required to achieve the same effect. The diagnosisofsubstancedependence requires substance use. 5. B.Withdrawal:Acharacteristic withdrawal syndrome occurs. Intoxication is defined as a reversible syndrome that develops following ingestion of a substance. or the substance isused in an effortto avoid withdrawal symptoms. but that knowledge .The patient attempts or desires to decrease use.
Asubstance-specificsyndromedevelops after cessation or reduction in the amount of substance used. 2. and day. Mydriasis (dilated pupils) is often seen in persons under the influence of stimulants or hallucinogens. VIII. V. gravitation toward others with similar lifestyle. Diagnosis requires meeting criteria for specific disorder with evidence that substance intoxication and not another condition (medical disorder) has caused the symptoms. IV. 5. or in withdrawal from opiates. psychotic disorder. Nystagmus is often seen in abusers of sedatives. B. hypnotics. Physical Examination A. Symptoms are not due to a medical condition or other mental disorder. Decline in work school performance. motor vehicle accidents. LaboratoryEvaluationofSubstance .Social Manifestations. Substance Withdrawal A. such as an enlarged liver.Work or School Manifestations. mood disorder. Arrests for disturbing the peace or driving while intoxicated. week. frequent absences. dementia. or cannabis.Financial Manifestations.Family Manifestations. Effects of Substance Use on the Patient's Life 1. B. spider angioma.Irresponsible borrowing or owing money. Substance-Induced Disorders A. selling of possessions. ascites. prostitution. The physician should determine the amount and frequency of alcohol or other drug use in the past month. C. sexual dysfunction. 3. and sleep disorder. divorce physical abuse and violence. and signs of poor nutrition are indicators of chronic alcohol use. VI. frequent job changes. impaired liver function. persisting amnestic disorder. Clinical Evaluation of Substance Abuse A. Family dysfunction. VII. Thesyndrome causes clinicallysignificant distress or impairment.requests forworkexcuses. anxiety disorder.and the quantityconsumed should be determined. drug dealing. IV drug abuse maybe associated with injection site scars and bacterial endocarditis. Miosis (pinpoint pupils) is a classic sign of opioid intoxication. Intranasal cocaine use may cause damaged nasal mucosa. B. For alcohol use. marital problems. the number of days per week alcohol is consumed.Legal Manifestations. B. The patient should be assessed for the withdrawal symptoms.does not deter continued use. stealing. 4. Substance-induced disorders include delirium. Alienation and loss of friends. C.
A UA. Impaired liver function and hematologic abnormalities are common.Abuse A. B. thyroid hormone. and serology should be completed on all patients. chemistry panel. CBC. C. Illicit drugs may be detected in blood and urine. When risk factors are present HIV and Hepatitis C testing should be done. . D. liver function tests.
Specific Substance-Induced Disorders Intoxication delirium Alcohol Amphetamine Caffeine Cannabis Cocaine Hallucinogens Inhalants Opioids PCP Sedative hypnotic I I I I I I IW I I I Withdrawal delirium Dementia Psychotic disorder Mood disorder Anxiety disorder Sexual dysfunction I I Sleep disorder W P IW I IW IW IW I IW IW I I IW I I I IW I I I I W P I I I I I I IW I I I W I IW IW P IW I = intoxication W = withdrawal P = persisting .
Two or more ofthe following:tachycardia or bradycardia. Sedatives or Hypnotics 1. the risk for respiratory depression is increased. Alcohol. Addiction 1. or impaired judgement. Dependence is associated with the development of tolerance to sedative effects. high or low blood pressure. 2. Hypnotics. To prevent withdrawal symptoms. the dose of medication should be reduced gradually over 1-2 weeks.” the risk for respiratorydepression is increased. impaired attention or memory. Sedatives associated withwithdrawal syndromesincludealcohol. Because the brainstem develops tolerance to the respiratorydepressant effects more slowly. and chloral hydrate. 2. stupor or coma. are present.” C. Tolerance develops to sedative effects. 2.benzodiazepines. Sedatives. 2. Behavioral and psychological changes are present. as users require higher doses to achieve a “high. Amnesia is often present. which has less risk of severe withdrawal symptoms. grandiosity. D. chills or perspiration. B.Specific Substance-Related Disorders I. 2. The cross-tolerated drug is given in gradually tapering doses. hypersexuality. Clinical Features of Intoxication 1. mydriasis (dilated pupils). and Anxiolytics A. such as euphoria. Diagnostic Criteria for Intoxication 1.nystagmus. or when there are signs of abuse or addiction. Detoxification of Patients Dependent on Alcohol. unsteadygait. Provide a supervised stepwise dose reduction ofthe drugorsubstitute a cross-tolerant. Detoxification may be necessary after prolonged use of central nervous system depressants. hyperactivity. 3. longer-acting substance (diazepam). anxiety. 2. Withdrawal from Alcohol and other Sedatives 1. barbiturates. II. Cocaine A. incoordination. nausea or . As users require higher doses to achieve a “high. Tolerance to brainstem depressant effects develops more slowly. Psychological or behavioral changes. Behavioral disinhibition (aggressive or sexual activity) is a common finding. Diagnostic Criteria for Intoxication 1. One or more of the following: slurred speech. E.
C. poor judgement. nasal congestion and bleeding. Clinical Features of Opioid Abuse 1. Treatment 1. Pinpoint pupils (meiosis). 2.dyskinesias. Diagnostic Criteria for Intoxication 1. clonidine. Tricyclic antidepressants(desipramine). coma. anxiety. Heroin withdrawal begins eight hours after the last use. withdrawal generally remits in 2-5 days. D. and death. 2.or impairment in attention or memory.amantadine.Psychological dependence is frequent. Drug craving may last for months. impulsivebehavior. weight loss. psychomotorretardation. or dystonia. Physical sequelae include seizures. B. anhedonia. Hospitalization is sometimes required during the withdrawal phase of treatment because of the intense craving. agitation or retardation. impaired judgement. Overdose can result in coma. 3. poor concentration. and arrhythmias. depression. IV use is associated with risk of AIDS. One of the following: drowsiness. confusion. B.respiratory depression. Initial euphoria is followed byapathy. Intoxication can resultin euphoria. Clinical Features of Cocaine Abuse 1. III. and personalitychange are common. Behavioral or psychological changes.andcarbamazepine may decrease craving and are often adjuncts to treatment. Intensityof the withdrawal syndrome is greatest with opiates that have a short half-life. skin abscesses. and weight loss. C. E. followed by dysphoria. Irritability.coma.vomiting. 2.weakness.arrhythmias. Chronic use is associated with paranoid ideation. 2.and psychomotorretardation. and bacterial endocarditis. respiratorydepression. D. Addiction. such as euphoria. 3. fatigue. dysphoria. aggressive behavior. peaks in 2-3 days and can last up to 10 days. Addiction. cerebral infarcts. Diagnosis of withdrawal requires the presence of three or more of the following: dysphoria.seizures. nausea. hypersomnia. and an intense craving for the drug. Withdrawalischaracterized bydepression. slurred speech. and perceptual disturbances. Withdrawal 1. insomnia. such as heroin. . or impaired social or occupational functioning.Tolerance and dependence develops rapidly. Tolerance develops with repeated use. Opioids A. 2.
vomiting. 2. Phencyclidine Abuse A. Psychosis is often refractory to treatment with antipsychotics. Physical Examination: Fever. rhinorrhea. difficulty communicating. diarrhea. Clonidine (0. fever. belligerence.(AlsoseeOpiateDependance. diaphoresis.1-0. Medical support is required if the patient is unconscious. muscle rigidity. lacrimation. For patientswithrespiratorycompromise an airway should be established and naloxone (0. Treatment of Heroin Addiction 1.4 mg IV) should be given immediately. impairment of attention or memory. psychosis. hyperacusis. C. and confusion. Toxicology: PCP can be detected in urine forupto5days after ingestion. E. and insomnia. hyperactivity. page 10) IV. mydriasis. hypertension or tachycardia. Treatment of Phencyclidine Abuse 1. D. yawning. decreased pain sensitivity. Withdrawal symptoms can be managed with methadone (20-80 mg/day) or clonidine (given orally or by patch). mydriasis. 2. Behavior changesinclude violence. IM or IV). sweating. piloerection. but tolerance to the effects can occur. Perceptual disturbances include paranoia. Withdrawal: Signs of depression can occur during withdrawal. 4. Addiction: No evidence of physical dependence occurs.3 mg qid) is effective and is usually used as a first-line treatment of withdrawal. 3. Diagnostic Criteria for Intoxication 1. . B. Clinical Features of Phencyclidine Abuse 1. seizure or coma. 3. ataxia. slurred speech. 2. catatonia. but drugs with anticholinergic side effects (phenothiazines) should be avoided due to the intrinsic anticholinergic effects of PCP. 2. Benzodiazepines are the treatment of choice (lorazepam 2-4 mg PO.hallucinations. Behavioral changes. Haloperidol (Haldol [2-4 mg IM/PO]) every two hours can be used. Atleasttwo ofthe following:nystagmus. anxiety.muscle aches. E.
C. 2. psychomotor agitation or retardation. insomnia. Antipsychotics can be used if psychosis is present. B. Patients should be prescribed a regimen that provides a tapering dose over a period of weeks. After abrupt cessation or reduction in the amount of nicotine used. Benzodiazepinessuchasdiazepam or lorazepam may also help calm the patient. rapid speech. decreased heart rate. Amphetamine Withdrawal 1. Depression and suicidal ideation can develop. Nicorettegumornicotine transdermal patches relievewithdrawal symptoms. Nicotine A. anxiety. Clinical Features 1. 2. E. irritability.Psychological dependence is frequent. D. restlessness. Diagnostic Criteria for Amphetamine Intoxication 1. C. insomnia. hypersomnia. Craving is often prominent. Crystal) A. Diagnostic Criteria for Withdrawal 1. four or more of the following occur within 24 hours:dysphoria. Treatment 1. 2. vivid dreaming. or irritability. B.or 4 mg piece/30 min . hyperactivity. Treatments for Smoking Cessation Drug Dosage Comments Available OTC. Generally resolves in one week and is associated with increased appetite. fatigue.agitation. increased appetite. Addiction: Tolerance develops rapidly.hypervigilance. D.anxiety.V. VI. Intoxication does not occur. requiring increasing doses to achieve usual effect.poor concentration. Amphetamine (Speed. Treatment 1. Developmentofdelusionsorhalucinations l are not unusual in chronic heavy users. E. Addiction:Physical tolerance develops. Euphoria and increased energy is common in new users. Behavioral or psychologicalchanges such as euphoria. poor compli ance Nico tine gum (Nicor ette) 2. Clinical Features 1.
Bupropion (Zyban) 1. It delivers a high level of nicotine. then taper for 4 wk 1-2 doses/h for 6-8 wk Rapid nic otine deliv ery. provides low doses of nicotine Treatment initiated 1 wk before quit day. Bupropion is contraindicated with a history of seizures. heavy al cohol use 6-16 car tridges/d for 12 wk 150 mg/day for 3 d. Bupropion is started at a dose of 150 mg daily for three days. . Tapering over about six weeks. anorexia. Bupropion reduces withdrawal symptoms and can be used in conjunction with nicotine replacement therapy. local skin reac tions Nico tine patch (Habitr ol. The sprayis used 6-8 weeks. or head trauma. anorexia. then titrate to 300 mg F. similar to nicotine gum. at 1-2 doses per hour (one puff in each nostril). Nicotine nasal spray (Nicotrol NS) is available by prescription and is a good choice for heavy smokers or patients who have failed treatment with nicotine gum or patch. H. heavyalcohol use.Drug Dosage Comments Available OTC. similar to smoking. Bupropion is appropriate for patients who have been unsuccessful using nicotine replacement. contraindi cated with seizures. G. The treatment is associated with reduced weight gain. Nicotine inhaler (Nicotrol Inhaler) delivers nicotine orally via inhalation from a plastic tube. 2. nasal irritation initially Mimics smoking behavior. Nicode rm CQ) Nico tine nasal spray (Nicotr ol NS) Nico tine inhaler (Nicotr ol In haler) Bupro pion (Zyban ) 1 patch/d for 6-12 wk. It is available by prescription and has a success rate of 28%.
. When a nicotine patch is added to this regimen. the abstinence rates increase to 50% compared with 32% when only the patch is used. Bupropion is then continued for three months. see page 121.then increased to 300 mg daily for two weeks before the patient stops smoking. References References.
Delirium is characterized byimpairments of consciousness. Perceptual disturbances may take the form of misinterpretations. illusions or frank hallucinations. The quietly delirious patient may reduce fluid and food intakewithoutovertlydisplaying agitated behavior. B. The disturbance develops over a short period of time (hours to days) and fluctuates during the course of the day. Other patients at risk include those with CNS disorders.attention and concentration. and HIV-positive patients. and combative behavior. III. D. and psychomotor agitation can be severe. A fluctuating clinical presentation is the hallmark of the disorder. C. Delirium due to a multiple etiologies (specify which conditions). awareness of environment. II. The incidence of delirium in hospitalized patients is 10-15%. C. Classification of Delirium A. Delirium due to a general medical condition (specify which condition). falling. Delirium due to a substance withdrawal (specify which substance). E. Disturbance of consciousness with reduced ability to focus. E. D.Thehallucinations are most commonly visual. Delirium not otherwise specified . substance abusers. There is clinical evidence that the disturbance is caused by a general medical condition and/or substance use or withdrawal. DSM-IV Diagnostic Criteria for Delirium A. and the patient may have moments of lucidity during the course of the day. resulting in pulling out of IVS and catheters. B. F. Infection and medication interaction or toxicity is a common cause of delirium in the elderly. Failure to report use of medications or substance abuse is a common cause ofwithdrawal deliriuminhospitalized patients. but other sensorymodalitiescanalsobemisperceived. D. sustain or shift attention. Clinical Features of Delirium A. The change in cognition or perceptual disturbance is not due to dementia. with higher rates in the elderly. Injuries may occur when the patient isdelirious and agitated and unrecognized delirium may result in permanent cognitive impairment. Many patients are disoriented and display disorganized thinking. Sleep-wake cycle disturbances are common. C. B.Cognitive Disorders Delirium I. Delirium due to substance intoxication (specify which substance).
small doses ofthe sedating. 1-2 mg given every 4-8 hours. Haloperidol may also be given IM. low-potency medication quetiapine (Seroquel) 12. Most cases of delirium are treated bycorrecting the underlying condition. Malingering. there should be some evidence of an underlying medical or substance-related condition. V. Delirium can be distinguished from psychotic symptoms by the abrupt development of cognitive deficits including disturbance ofconsciousness. confusion. Informationfromfamilyor caretakers is helpful in determining whether there was a pre-existing dementia. Patients with malingering lack objective evidence of a medical or substance-related condition. IM or IV. A quietenvironmentwithclose observation should be provided. . Dementia 1. Agitation can also be treated with lorazepam (Ativan). Dementia is the most common disorder that must be distinguished from delirium. It may cause increased confusion.5-25 mg every 4-8 hours can be veryeffective.(unknown etiology or due to other causes such as sensory deprivation). Monitoring of heart rate and blood pressure is necessary in patients receiving more than two dosesperday. B. In delirium. The major difference between dementia and delirium is that demented patients are alert without the disturbance of consciousness characteristic of delirious patients. Psychotic Disorders and Mood Disorders with Psychotic Features. Physical restraints may be necessary to prevent injury to self or others. IV. Intravenous administration may be necessary in medically ill patients. B. 1-2 mg every 2-6 hours PO.Parenteral forms of ziprasidone (Geodon) and olanzapine (Zyprexa) may have a role in managing delirium. D. and perceptual disturbances mayrequire treatment with haloperidol (Haldol). 2. Differential Diagnosis of Delirium A. Agitation. E. Haloperidol is the only antipsychotic available in IV form. C. If patients are willing to take oral medication. Treatment of Delirium A. C. Lorazepam is safe in the elderlyand those patients with compromised renal or hepatic function. It should be used cautiously in patients with respiratorydysfunction.
Agnosia (failure to recognize or identify objects). Once the dementia is well established. cooking. d. Apraxia (impaired ability to carry outpurposeful movement. Epidemiology of Dementia A. D. 1. or shopping. B. Three percent of patients over 65 years old have dementia. Patients are often unaware of their deficits. B. patients may have great difficulty performing activities of daily living such as bathing. Disinhibition can lead to poor social judgment. The memory impairment involves difficulty in learning new material and/or forgetting previously learned material. Memory impairment. 3. Aphasia (language disturbance). Patients may overestimate their ability to safely carry out specific tasks.Dementia I. but after age 85. C. 20% of the population is affected. III. b. Clinical Features of Dementia A. One or more of the following: a. The prevalence of dementia increases with age. Vascular dementia is the second most common cause of dementia. and sleep disturbance. Disturbance in executive functioning (abstract thinking. F. accounting for 13% of all cases. II. 2.suchasmakinginappropriate comments. E. The cognitive deficits cause significant social and occupational impairment and represent a significant decline from a previous level of functioning. IV. Early signs may consist of losing belongings or getting lost more easily.comprising 50-60% of all cases. Delirium is frequently superimposed upon dementia because these patients are more sensitive to the effects of medications and physical illness. The deficits are not the result of delirium. C. Alzheimer's type dementia is the most commontype ofdementia. depression. B.especially the use of objects). Classification of Dementia . Paranoid delusions (especiallyaccusations that others are stealing items) and hallucinations (especially visual) are common. planning and carrying out tasks). Psychiatric symptoms are common and patients frequentlymanifest symptoms of anxiety. DSM-IV Diagnostic Criteria for Dementia A. dressing. c. Poor insight and impaired judgment are common features of dementia. 2. The development of multiple cognitive deficits manifested by: 1.
leaving some cognitive functions intact. Focal neurological signs and symptoms or laboratoryevidence of cerebrovascular disease (eg. Meets basic diagnostic criteria for dementia. d. apathy. The patient meets basic diagnostic criteria for dementia but also: a. social withdrawal. C. 3. b. c. Gradual onset and continued cognitive decline. The one notable exception is dementia pugilistica.delusions. AIDS-Related Dementia a. depressed mood. 3. 5. Vascular Dementia (previously Multi-Infarct Dementia) 1. The dementia is often exaggerated bythe presence of major depression. and the long-term course tends to have a stepwise pattern. 2. Unlike Alzheimer's disease. impaired problem solving. 4. Dementia Due to Other General Medical Conditions 1. Frank psychosis maybe present. Cognitive deficits are not due to another medical condition or substance.depressed mood. B. The average life expectancy after onset of illness is 8-10 years. b.Deficits are highlyvariable depending on the location of the vascular lesions. Withdelirium. b. multiple infarctions or MRI scan). Vascular dementia is further classified as withdelirium.A. Clinical presentation includes psychomotorretardation. Dementia caused byhead trauma usually does not progress. b. Alzheimer's Type Dementia 1. or uncomplicated. oruncomplicated. Symptoms are not caused by another psychiatric disorder. Dementia Caused byParkinson's Disease. Alzheimer’s Disease is further classified as: a. Dementia caused by the effect of the HIV virus on the brain. 2. boxing). The patient meets basic diagnostic criteria for dementia but also has: a. Neurological symptoms are frequently present. but there must also be evidence that symptoms are the directphysiological consequence of a general medical condition.Dementia occurs in 40-60% of patients with Parkinson's disease. DementiaCaused byHuntington's Disease a. c. which is caused by repeated trauma (eg. flat affect. c. DementiaCaused byHead Trauma.forgetfulness. Early or late onset.delusions. Dementia is an inevitable outcome . changes in functioning may be abrupt.
This diagnosis is applicable when multiple disorders are responsible for the dementia. b. Lewy Body Dementia a. The deficits persists beyond the usual duration ofsubstanceintoxication or withdrawal. i and executive function are more seriously impaired. DementiaCaused byPick's Disease a. Meets basic diagnostic criteria for Dementia but also: a. There is evidence that the deficits are related to the persisting effects of substance use (specify which drug or medication). neuroleptic sensitivity. DementiaCausedbyCreutzfeldt-Jakob Disease a. D. Occasionally patients will improve mildly after thesubstanceusehasbeendiscontinued. Substance-Induced Persisting Dementia 1. c. 6. Brain imaging studies usually reveal frontal and/or temporal atrophy. Characterized by decline in cognition along with fluctuating levels of attention and alertness. but most display a progressive downhill course. 3. and periodic EEG activity. Clinical presentation is that of a typical dementia. Creutzfeldt-Jacob disease is asubacutespongiformencephalopathy caused by a prion. at some time in their lives.and language abnormalities because Pick's disease affects the frontal and temporal lobes.of this disease. 7. b. b. . b. b. When drugs of abuse are involved. 2.metcriteria for substance dependence. delusions and hallucinations. apathy. most patients have. Occasionally. Recurrent.reasoning. language and factual knowledge may be relatively preserved. Initially. The earlyphases of the disease are characterized bydisinhibition. syncope. dementia can precede the onset of motor symptoms. well-formed visual hallucinations are also common. The clinical triad consists of dementia. involuntarymyoclonic movements. Dementia Due to Multiple Etiologies. 8.whle memory. Lewybodydementia is associated with repeated falls. transient loss of consciousness. Later stages of the illness may byclinicallysimilar to Alzheimer's disease. E.
2. without the cognitive deficits seen in dementia. Delirium 1. SLE) Neurological Normal pres sure hydroceph alus Huntington’s disease Parkinson’s dis ease Pick’s disease Brain tumor Multiple sclero sis Head trauma Cerebral an oxia/hypoxia Seizures Metabolic and Endocrine Hypothyroidism Hyperparathyroi dism Pituitary insuffi ciency Diabetes Hepatic encephalopathy Uremia Porphyria Wilson’s dis ease Toxicity Heavy metals Intracranial radi ation Post-infectious encephalomyelit is Chronic alcohol ism Nutritional Folate defi ciency Vitamin B12 deficiency Thiamine defi ciency (Wernicke Korsakoff syn drome) Pellagra Infections HIV Cryptococcal meningitis Encephalitis Sarcoid Neurosyphilis CreutzfeldtJakob disease Industrial chemicals V. . Differentiation of delirium from dementia can be difficult because demented individuals are prone to developing a superimposed delirium.General Medical Conditions That Can Cause Dementia Vascular Multiple in farcts Subacute bac terial endocarditis Congestive heart failure Collagen vas cular diseases (eg. downhill course. slowlyprogressive. whereas demented patients displaya stable. Differential Diagnosis of Dementia A. Amnestic Disorder is characterized by isolated memory disturbance. Delirium is the most common disorder that maymimic dementia. Delirious patients demonstrate an acutely fluctuating clinical course. B.whereas. Demented patients are alert. delirious patients have an altered level of consciousness.
C. atrialofantidepressants is warranted. The family and/or caretakers should receive psychological support. Complete blood chemistry. Some causes of dementia are treatable and reversible. M. Both dementia and depression may present with apathy. Thyroid function tests.C.” 2. VII. Drug screen. Urinalysis. Differentiation of dementia from depression can be difficult. Treatment of Alzheimer's Disease 1. Cognitive deficits due to a mood disordermayappear tobe dementia. If the distinction between dementia and depression remains unclear. F. I. B. poor concentration.Indepression. EKG. Vitamin B12 level. K. psychotherapy. B. B. Serum levels ofall measurable medications. Treatment of Dementia A. L. MRI) is indicated if there is a suspicion of CNS pathology. 3. VI. H. J. Chest X-ray. and impaired memory. Heavy metal screen. CBC with differential. G. Major Depressive Disorder 1. Brain Imaging (CT. Any underlying medical conditions should be corrected. The use of CNS depressants and antichoinergic medications l should be minimized. such as a mass lesion or vascular event. andthisisreferredtoas“pseudodementia. Donepezil (Aricept)andGalantamine . Support groups. Patients function best if highlystimulating environments are avoided. VIII. with special attention to the neurological exam. especially in the elderly. themood symptoms shouldprecede the development of cognitive deficits and in dementia. Serological studies (VDRL or MHA-TP). Demented patients are often alsodepressed. should be completed. If the depression is superimposed on the dementia. All patients presenting with cognitive deficits shouldbeevaluated todetermine the etiology of the dementia. D. Laboratory Evaluation of Dementia A. A medical and psychiatric history and a physicalexamination and psychiatric assessment. 4. and day-care centers are helpful. A medical evaluation to rule out treatable causes of dementia or medical causes of depression should be completed. EEG. C. treatment of the depression will improve the functional level of the patient. E. Clinical Evaluation of Dementia A. and the cognitive symptoms should precede the depression.
beginning .5-25 mg po qhs with an increase of 12. Beginning dose is 5 mg qhs for donepezil. a. b.diarrhea and syncope. GI side effects are reduced by coadministration with food. reversible inhibition of acetylcholinesterase thereby increasing CNSlevels ofacetylcholine. Treatment of Vascular Dementia 1. There is no hepatic toxicity. Tacrine (Cognex) is a less specific esterase inhibitor that requires monitoring of AST and SLT levels. Quetiapine (Seroquel) 12.0 mg po bid for 4 weeks.0 mg bid at two-week intervals. Dosing is begun at 1. E. 2. Agitation and Aggression 1. b. Efficacy is greatest at the higher dose. Hypertension must be controlled. Side effects include GI upset or diarrhea. Buspirone has fewside effects and no significant drug interactions.0 mg po bid if tolerated for 4 weeks. Vitamin E and selegiline (Deprenyl) may also have a role in slowingthe progression ofdementia. It may slow progress of the disease. Risperidone (Risperdal). Aspirin may be indicated to reduce thrombus formation. Galantamine (Reminyl)is initiated at 4. Vitamin E. Tacrineisnotusedduetoitshepatotoxicity.Donepezil has no reported hepatic toxicity or significant drug interactions. D. which (after 4-6 weeks) may be increased to 10 mg qhs ifnecessary.5 mg bid. 3. a. 2. d. Trazodone (Desyrel) beginning at 25-50 mg qhs with an average dose of 50-200 mg/day. c. They work bycentral. The most common side effects are nausea. and then up to 12 mg po bid.5 mg bid and then 6. then increased to 8. and increased to 4. Buspirone (BuSpar) beginning at 5 mg bid with a final dose of 30-50 mg/day in bid or tid dosing. 4. b.5 to 25 mg every1-3 days if needed to an average dose of25-200 mg/dayand amaximum dose of 400-600 mg/day. Ri asi mine(Exelon)isanacetychoinest rase v tg l l e inhibitor with a similar mechanism of action asdonepeziland galantamine. a. Pharmacotherapy: The following agents have significant efficacy in reducing agitation and aggression in dementia.(Reminyl) are the drugs of choice for improving cognitive functioning in Alzheimer’s dementia. Several weeks are required to achieve full benefit.
Venlafaxine (Effexor) (37. 2. i. f. F. risperidone. g. SSRIs are first-line antidepressants in the elderly. and olanzapine are less likelyto produce extrapyramidal symptoms and are preferred over typical antipsychotics. trazodone (Desyrel). Tricyclic antidepressants should be avoided in patients with dementia because of their anticholinergic effects. Psychosis 1.5 mg qhs with an average dose of 2.further memoryimpairment. Olanzapine(Zyprexa). Depression 1. and potential for disinhibition and physical dependence. 0. can provide rapidreief.5 mg BID to 150 mg bid) is useful. G. butit is notrecommended l for long-term use because of ataxia.5-5 mg/day given qhs or bid.5-7. such as haloperidol or fluphenazine.0 mg q 4 hours prn. References References. Haloperidol (Haldol) may be used if risperidone or olanzapine are ineffective. ziprasidone. nefazodone (Serzone) and mirtazapine (Remeron) may also be used if SSRIs are ineffective.5-1.25-0.at0.5 mg qhs with an average dose of 2. bupropion (Wellbutrin). Several days should elapse between dosageincreasestopreventovermedication and oversedation. Serum levels should be maintained between 25-75 mg/mL. should be given only at very low doses. Lorazepam (Ativan). h.is especially effective for agitation associated with psychotic symptoms such as paranoia.5 mg qhs. Ziprasidone (Geodon) 20 mg po bid with increases of 20 mg every 1-3 days as needed with maximum daily dose of 80 mg po bid. Dose range is 0. Divalproex (Depakote) at a dosage of10 mg/kg/day(250-1250 mg/day bid) is effective and well tolerated bymanydemented patients.5-2 mg day. . e. 2.5mgqhs withan average dose of 0. see page 121. High-potencytypical antipsychotics. Quetiapine.beginning at 2. also reduces agitation in dementia.5-7.
B. 2. The patient meets the criteria for a mental disorder due to a general medical condition and there are prominent hallucinations or delusions. The disturbance isnot better accounted for by another mental disorder. Temporal Lobe Epilepsyisacommon medical condition associated with olfactoryhallucinations. Common Disorders Associated with Psychosis Addison's dis ease CNS infections CNS neoplasms CNS trauma Cushing's dis ease Delirium Dementias Folic acid defi ciency Huntington's chorea Multiple sclero sis Myxedema Pancreatitis Pellagra Pernicious anemia Porphyria Lupus Temporal lobe epilepsy Thyrotoxicosis C. or laboratory studies that the symptoms are a direct physiological consequence of a general medical condition. b. There is evidence from the history. Primary Psychotic Disorders a. ClinicalFeaturesofPsychoticDisorder Due to a General Medical Condition 1. olfactory and tactile elements more often than in primarypsychotic disorders. with symptoms beginning prior to the onset of the medical illness. Non-auditory . B. Complex auditory hallucinations are more characteristic of primary psychotic disorders. Somatic and persecutory delusions are the mostcommon typesofdelusions associated with a medical condition. The onset of illness in a primary psychotic disorder is usually earlier (before age 35). physical examination.Mental Disorders Due to a Medical Condition I. Differential Diagnosis of Psychotic Disorder Due to a General Medical Condition 1. Psychotic DisorderCaused byaGeneral Medical Condition A. Diagnostic Criteria. Hallucinations caused bya medical condition include visual. DSM-IV Diagnostic Criteria for Mental Disorder Due to a Medical Condition A. The disturbance is not caused by delirium. C. II.
activities. or irritable mood. Meets criteria for a mental disorder due to a general medical condition. The underlying medical conditions should be corrected. D.ifnot all. Diagnostic Criteria.amphetamines. steroids. cocaine. . The mood symptoms cannot be a merely psychological reaction to being ill.hallucinations (eg.tactilehallucinations) are more commonly seen in general medical conditions. d. 2. c. withdrawal from a substance is the likelycause. b. Mood disorder due to a general medical condition with depressive features. and the presence of a prominent and persistent mood disturbance characterized by either or both of the following: 1. b.and disulfiram. 2. Elevated. expansive. III. Blood or urine screens for suspected substances may be helpful in establishing this diagnosis. Subtypes include: a. Mood disorder due to a general medical condition with mixed features. 2. Clinical Features of Mood Disorder Due to a General Medical Condition 1. A trial of antipsychotic medication may be necessary to manage symptoms while the patient's medical condition is being treated. Substances that can cause psychosis: anticholinergics. Mood DisorderDuetoa General Medical Condition A. Substance-Induced Psychotic Disorder a. hallucinogens. Mood disorder due to a general medical condition with manic features. Treatment of Psychotic Disorder Due to a General MedicalCondition 1. With depressed mood or lack ofpleasure in most. Mood disorder due to a general medical condition with major depressive-like episode. When psychosis is associated with recentorprolonged substance use. B.L-dopa. 2.
Common Diseases and Disorders Associated with Depressive Syndromes Addison's dis ease AIDS Asthma Chronic infec tion (mononu cleosis, tuberculosis) Heart failure Cushing's dis ease Diabetes Hyperthyroidis m Hypothyroidism Infectious hep atitis Influenza Malignancies Malnutrition Anemia Multiple sclero sis Porphyria Rheumatoid arthritis Syphilis Lupus Uremia Ulcerative coli tis
C. Differential Diagnosis of Mood Disorder Due to a General Medical Condition 1. Primary Mood Disorder. If a clear causativephysiologicalexplanation cannot be established between mood symptoms and the medical condition, a primarymood disorder should be diagnosed. Fluctuation of mood symptoms during the course of medical illness is indicative of a disorder due to a medical condition. 2. Substance-Induced Mood Disorder a. When the mood disorder is associated withrecentor prolonged substance use or withdrawal from a substance and psychotic symptoms,a substance-induced mood should be diagnosed. Blood or urine screens may be helpful in establishing this diagnosis. b. Common substances that can cause depressive syndromes include antihypertensives, hormones (cortisone, estrogen, progesterone), antiparkinsonian drugs,benzodiazepines, alcohol, chronic use ofsympathomimetics, i andwthdrawalfrompsychostimulants. 3. Treatment of Mood Disorder DuetoaGeneralMedical Condition. The underlying medical condition should be corrected. References References, see page 121.
Anorexia Nervosa I. DSM-IV Diagnostic Criteria for Anorexia Nervosa A. The patient refuses to maintain weight above 85% of expected weight for age and height. B. Intense fear of weight gain or of being fat, even though underweight. C. Disturbance in the perception of ones weight and shape, or denial of seriousness of current low weight. D. Amenorrheaforthreecyclesinpost-menarchal females. II. Classification of Anorexia Nervosa A. Restricting Type or Excessive Dieting Type. Binging or purging are not present. B. Binge-Eating Type or Purging Type. Regular binging and purging behavior occurs during current episode (purging maybe in the form of vomiting, laxative abuse, enema abuse, or diuretic abuse). III. Clinical Features of Anorexia Nervosa A. Anorexia nervosa is characterized by obsessive-compulsive features (counting calories, hoarding food), diminished sexual activity, rigid personality, strongneed tocontrolonesenvironment, and social phobia (fear of eating in public). Anorexia nervosa commonly coexistswith major depressive disorder. B. Complications of Anorexia Nervosa. All body systems may be affected, depending on the degree of starvation and the type of purging. Leukopenia and anemia, dehydration, metabolic acidosis (due to laxatives), or alkalosis (due to vomiting), diminished thyroid function, low sex hormone levels, osteoporosis,bradycardia,andencephalopathy are commonly seen. C. Physical signs and symptoms may include gastrointestinal complaints, cold intolerance, emaciation, parotid gland enlargement, lanugo hair, hypotension, peripheral edema, poor dentition, and lethargy. IV. Epidemiology of Anorexia Nervosa A. Ninety percent of cases occur in females. The prevalence in females is 0.5-1.0%. The disorder begins in early adolescence and is rare after the age of forty. Peak incidences occur at age 14 and at age 18 years. B. There is an increased risk in first-degree relatives,and there is a higher concordance rate in monozygotic twins. Patients withahistoryofhospitalization secondary to anorexia have a 10% mortality rate. V. Differential Diagnosis of Anorexia Nervosa A. Medical Conditions. Malignancies,
AIDS, superior mesenteric artery syndrome (postprandial vomiting due to gastric outlet obstruction) are not associated with a distorted body image nor the desire to lose weight. B. BodyDysmorphic Disorder.Additional distortions of body image must be present to diagnose this disorder. C. Bulimia Nervosa. These patients are usually able to maintain weight at or above the expected minimum. VI. Laboratory Evaluation of Anorexia Nervosa. Decreased serum albumin, globulin,calcium hypokalemia,hyponatremia, anemia, and leukopenia maybe present. ECG may show prolonged QT interval or arrhythmias. VII.Treatment of Anorexia Nervosa A. Psychotherapiesinclude psychodynamic psychotherapy,familytherapy,behavioral therapy, and group therapy. B. Pharmacotherapy of Anorexia Nervosa 1. Two-thirds ofpatients with anorexia or bulimia nervosa have a history of a major depressive episode. Fluoxetine (Prozac) has been used successfully in the therapy of anorexia and bulimia; 20-60 mg per day. 2. Hospitalization maybecomenecessary if weight loss becomes severe or if hypotension, syncope, or other cardiac problems develop. Specialized treatment programs, including behavioral treatment focusing on weight gain, family psychotherapy,oral intakemonitoring with dietary consultation, and pharmacotherapy are effective in motivated patients.Close monitoring of body weight and the general medical condition is warranted.
I. DSM-IV Diagnostic Criteria for Bulimia Nervosa A. The patient engages in recurrent episodes of binging, characterized by eating an excessive amount of food within a two-hour span and by having a sense of lack of self-control over eating during the episode. B. The patient engages in recurrent compensatory behavior to prevent weight gain (eg, self-induced vomiting, laxative, diuretic, exercise abuse). C. The above occur on the average twice a week for three months. D. The patient’s self-evaluation is unduly influenced by body shape and weight. E. Thedisturbance does notoccurexclusively during episodes of anorexia nervosa. II. Classification of Bulimia Nervosa A. Purging Type Bulimia Nervosa.
The patient regularlyengages in fasting or exercise. Nonpurging Type Bulimia Nervosa. and binging and purging behavior occurs. and death rarely occurs in bulimia. C. Purging can be associated with poor dentition (because of acidic damage to teeth). B. hypokalemia). Menstrual abnormalities are frequent. Antidepressant medications are useful in the treatment of bulimia nervosa. but not vomiting or laxatives. Binging Purging Type Anorexia Nervosa. to a daily dose of 150 mg. 3. III. Other SSRIs are also effective. Cognitive behavioral therapy is the most effective treatment. Psychodynamic group and family therapies are also useful. The serum drug level is measured after one week. There is an increased frequency of affective disorders. and weight are absent. and various degrees of starvation can occur. There is a higher incidence of affective disorders in families of patients with bulimia. Pharmacotherapyof Bulimia Nervosa 1.The patient regularly makes use of self-induced vomiting.3% in males. Electrolyte abnormalities (metabolic alkalosis. Clinical Features of Bulimia Nervosa A. 2. B. Prognosis is generally better than for anorexia nervosa. and obesityis more common. whether or not accompanied by major depression. V. and laxatives.1-0. Overeating occurs in the absence of compensatory purging behaviors. C. B. IV. Atypical Depression. concern with body shape. Unlike anorexia patients. Bulimia occurs primarilyin industrialized countries. Body weight is less than 85% of expected. Bulimic patients tend to be ashamed of their behavior and often hide it from their families and physicians. . bulimic patients tend to be at or above their expected weight for age. VI. Differential Diagnosis of BulimiaNervosa A. and borderline personality disorder (30%) in bulimia patients. dehydration. increasing by 50-mg increments every 3-4 days. symptoms of binging and purging are reduced. B. Treatment of Bulimia Nervosa A. substance abuse (30%). Epidemiology of Bulimia Nervosa A. and the incidence is 1-3% in adolescent and young adult females and 0. and concern over bodyshape and weightis notpredominant. Imipramine (Tofranil) or desipramine (Norpramin) at a low dosage (50 mg per day). Medical Conditions with Disturbed Eating Behaviors. Fluoxetine (Prozac) is effective at a dosage of 20-60 mg per day. B. Loss of control.
” weight gain. or self-deprecating thoughts. Clinical Features of Premenstrual Dysphoric Disorder A. Patients with PMDD do not experience symptoms in the week following menses. References References. C. Marked affective lability. Marked anxiety. Decreased interest in activities. joint or muscle pain. such as Major Depression. or specific food cravings.Asubjectivesenseofbeingoverwhelmed or out of control. Persistent and marked anger or irritabilityor increasedinterpersonal conflicts. 9.hopelessness. and were absent in the week after menses. 8. Premenstrual Dysphoric Disorder Premenstrual Dysphoric Disorder (PMDD) is characterized by depressed mood prior to the onset of menses. In most menstrual cycles over the past year. 6. The disturbance markedly interferes with work or school or usual social activities and relationships with others.4. 4. II. feeling “keyed up” or “on edge.Dysthymic Disorder. (2). (3). Bupropion is contraindicated because of the increased risk of seizures in bulimic patients. 5. Markedchange in appetite. DSM-IV Diagnostic Criteria A. Patients who have continued symptoms after the onset of menses . I. see page 121. 11.Panic Disorder. began to remit soon after the onset of the follicular phase.overeating. Subjective sense of difficulty in concentrating. 10. Hypersomnia or insomnia. or marked lack of energy. Criteria A. D. The disturbance is not merely an exacerbation of the symptoms of another disorder.Physical symptoms. 5 or more symptoms were present most of the time in the last week of the luteal phase. or (4): 1. headaches. easy fatigability. with at least one of the symptoms being either (1). tension. B and C must be confirmed by prospective daily ratings during at least two consecutive symptomatic cycles. such as breast tenderness or swelling. B. Lethargy. a sense of “bloating. 7. Markedlydepressedmood. 2. or a Personality Disorder.” 3.
The prevalence of PMDD ranges from 2-10% in women. Spironolactonemayimprove physical symptoms. SSRIs. Sertraline should be started at 50 mg per day and increased up to 150 mg if necessary. IV. V. III. . such as bloating. B. PMDD is diagnosed only when symptoms lead to marked impairment in social and occupational functioning. D. however. C. are effective in reducing symptoms of PMDD. Premenstrual Syndrome. Other SSRIs are equally effective. however. progesterone and triphasic oral contraceptives may improve symptoms of PMDD in some patients. B. Onset usually occurs in the mid to late twenties. Females with disorders such as dysthymia or generalized anxiety disorder mayexperience a premenstrual exacerbation of their depressive or anxietysymptoms. such as fluoxetine (marketed as Sarafem for PMDD). Anxiolytics.mayhave another underlyingpsychiatric disorder. Differential Diagnosis of Premenstrual Dysphoric Disorder A. Premenstrual Exacerbation of a Current Mood or AnxietyDisorder. These agents are often effective when given only during the luteal-phase. Estrogen. patients with PMDD have symptoms only prior to and during menses. The dosage of fluoxetine (Sarafem) is 20 mg per day throughout the month.These individuals will continue to meet criteria for a mood or anxiety disorder throughout the menstrual cycle. The dosage may be increased up to 60 mg per dayif necessary. EpidemiologyofPremenstrualDysphoric Disorder A. Antidepressants. B. onset in the teenage years may sometimes occur. Sertraline (Zoloft) is also effective in treating PMDD. Concomitant unipolar depression or bipolar disorder or a family history of affective illness is common in patients with PMDD. Hormones. The most severe symptoms of PMDD usually occur in the few days prior to menses. Many females experience mild transient affective symptoms around the time of their period. B. Alprazolam (Xanax) and buspirone (BuSpar) may have efficacy in treating patients with mild symptoms of anxiety. Treatment of Premenstrual Dysphoric Disorder A. It is uncommon for women with dysmenorrhea to have PMDD and uncommon for women with PMDD to have dysmenorrhea.
E. Moderate exercise can lead to improvement of physical and emotional symptoms of PMDD. Exercise. .
ziprasidone. Brief to moderate courses are usually used. however.schizophreniform disorder and schizophrenia. A.Psychiatric Drug Therapy Antipsychotic Drug Therapy I. B. B. olanzapine. C. The choice of neuroleptic should be made based on the past history of response to a particular neuroleptic. Symptoms will often continue to improve over the following months. and likelihood of tolerance to side effects. III. D. can be initiated with once-a-day dosing. They also playa prominent role in the treatment of schizoaffective disorder. Initial treatment should begin with divideddoses ofthe chosen antipsychotic. Dosing of Antipsychotic Agents A.however. such as depression and bipolar disorder. such as two to four times per day. with the exception of clozapine. and aripiprazole) may be more effective than conventional agents. Antipsychotics are frequently used in the treatment of substance induced psychoticdisorders. Thenewer“atypical” antipsychotics (risperidone. Antipsychotics (also known as neuroleptics) are indicated for schizophrenia. Selection of an Antipsychotic Agent. Once steady state levels have been achieved (after about five days). II. familyhistoryof response. quetiapine. B. the long half-life of most neuroleptics allowsforonce-a-daydosing. At least two weeks of treatment is required before significantantipsychotic effect is achieved. Olanzapine (Zyprexa). These agents often improve functioning in patients with dementia or delirium with psychotic features when given in low doses. . Antipsychotics are the drugs of choice forbrief psychotic disorder.ziprasidone and the low-potency typical agents. These newer agents are called atypical because they affect dopamine receptors and also have prominenteffects on serotonergicreceptors. which is more effectivefor treatmentrefractoryschizophrenia. All neuroleptics are equally effective in the treatment of psychosis. The use of more than one antipsychotic agent at a time has not been shown to increase efficacy. Indications for Antipsychotic Drugs A.Low-dose neuroleptics maybe useful for the psychotic features ofsevere personalitydisorders. and these agents may be used for other disorders with psychotic features. Antipsychotics may be necessary for patients with mood disorders with psychotic features. they should be used with caution and for a brief period of time in these patients.
such as chlorpromazine. C. Agitated psychotic patients are best treated initially with sedating agents such as benzodiazepines combined with a neuroleptic. . should be given in divided doses.
Classification of Antipsychotic Drugs Name Trade name Class Average Dose (mg) ChlorproDopaminermazine gic Equivalents Effect (D2) (mg) 100 ++++ Muscarinic Effect Alpha-1 Adrenergic Blocking Effect ++++ Antihis tamine Effect ++++ Serotone rgic Effect ++++ Chlorpromazine Fluphenazine Thorazine Prolixin Phenothia zine/Aliph atic Phenothia zine/Piper azine Phenothia zine/Piper azine Phenothia zine/Piper azine Phenothia zine/Piper idine Phenothia zine/Piper idine 600-800 ++++ 10-20 2 ++++ + + ++ ++ Perphenazine Trilafon 60-80 10 ++++ + ++ +++ ++++ Trifluoperazine Thioridazine Stelazine 30-40 5 ++++ + ++ ++ +++ Mellaril 600-800 100 ++++ ++++ ++++ ++++ ++++ Mesoridazine Serentil 300-400 50 ++++ +++ ++++ ++++ ++++ .
5 1 ++++ ++ ++++ +++ ++++ Muscarinic Effect Alpha-1 Adrenergic Blocking Effect + ++++ ++ +++ + Antihis tamine Effect + ++++ ++ ++++ + Serotone rgic Effect ++ ++++ +++ ++++ Haloperidol Clozapine Aripiprazole Loxapine Pimozide Haldol Clozaril Abilify Loxitane Orap Butyrophe.Name Trade name Class Average Dose (mg) ChlorproDopaminermazine gic Equivalents Effect (D2) (mg) 2 60 2-4 12.10-20 none Dibenzodiazepine Quinolinon e Dibenzodi azepine Diphenylb u ylpiperidin e Dihydroindolone Thioxanthene 300-600 15-30 75-100 2-15 + ++++ + ++ + Molindone Thiothixene Risperidone Moban Navane 50-100 30-40 2-8 10 5 1-2 +++ ++++ ++ ++ + + + ++ +++ + +++ ++ + + +++ Risperdal Benzisox azole .
Name Trade name Class Average Dose (mg) ChlorproDopaminermazine gic Equivalents Effect (D2) (mg) 3 +++ Muscarinic Effect Alpha-1 Adrenergic Blocking Effect ++ Antihis tamine Effect ++ Serotone rgic Effect +++ Olanzapine Zyprexa Zydis Thienobe n zodiazepin e 5-20 ++ Quetiapine Ziprasidone Seroquel Dibenzoth iazepine Geodon Benzisothi azolyl pip erzine 400-600 80-160 50 5-10 + +++ 0 + ++ + ++ + ++ +++ .
The dose may be reduced by 25% in each of the nexttwo monthsuntil the maintenance dose is 200 mg every 30 days.suchashaloperidol and fluphenazine. For example. Antipsychotic Side Effects The following discussion is applicable primarily to the typical antipsychotics.suchaschlorpromazine. 1. neuroleptic malignant syndrome.and akathisia. Low-potencyagents. 2. Haldol. sedation and orthostatic hypotension compared to high-potency agents such as haloperidol. produce a high incidence of extrapyramidal symptoms such as acute dystonic reactions. Parkinsonian syndrome.IV. tardive dyskinesias. Long-acting risperidone is expected to be approved in late 2003. the oral antipsychotic can be discontinued. Route of Administration A. Prolixin decanoate should be started at 25 mg IM every two weeks with the dose adjusted up to 50 mg every two weeks if necessary.and Prolixin decanoate are useful for non-compliant patients. Haldol 5-10 mg is often given in conjunction with 1-2 mg of IM Ativan. V. . C. B. 4. Haldol decanoate shouldbestarted at twenty times the daily oral dose in the first month of treatment. a patient receiving 20 mg of oral haloperidol per day would be given 400 mg of decanoate. and anticholinergic side effects. produce a higher incidence ofanticholinergic side effects. Atypical agents have a relatively low incidence of extrapyramidal effects. 3. divided intothreeorfour IMinjections given over a seven-day period. The recommended dose of IM ziprasidone is 10 mg every 2 hours or 20 mg every 4 hours as required up to a maximum daily dosage of 40 mg. Once a patient has received one or two injections. Oral formulations are available for all antipsychotics and some are available in liquid or orallydisintegrating form for elderly patients or to increase compliance in patients who “cheek” their medications and later spit them out. Thorazine is usually given 25-50 mg IM with close monitoring of blood pressure. B. A. which provides sedation. Long-acting intramuscular (depot) neuroleptics. Short-actingIMformulations ofziprasidone and olanzapine are available. High-potencyagents. such as risperidone (Consta). Haloperidol (Haldol) and chlorpromazine (Thorazine) are often used in IM form to treatacutelyagitated psychotic patients.
Patients withParkinsoniansyndrome secondarytoneuroleptics present with cogwheel rigidity. Neuroleptics. and urinary retention. D. requiring urgentintravenous administration of diphenhydramine. such as chlorpromazine and thioridazine. Moderate-potency agents include trifluoperazine and thiothixene and have side effect profiles in between the low. such ashaloperidol. 3. Extrapyramidal Side Effects (EPS) 1. . d. Neuroleptics. These involuntary movements occur due to blockade of dopamine receptors in the nigrostriatal pathway of the basal ganglia. b. Dystonias will often improve with a change to a lower potency or atypical agent. c. and can occurin young.and shuffling gait. constipation.produce antichoinergic l side effects such as dry mouth. Dystonic reactions are most frequentlyinduced byhigh-potency neuroleptics such as haloperidol and fluphenazine (Prolixin). bradykinesia. Dystonias are often very painful and frightening to patients. Subsequently. jaw and other muscle groups. Acute dystonic reactions are sustained contraction of the muscles of neck (torticollis). dryflushed skin.C. anticholinergic blockade can produce a central anticholinergic syndrome characterized byconfusion or delirium.especialythe high-potency agents. otherwise healthy persons (particularly younger men) even after a single dose.Laryngeal spasms can cause airway obstruction.and high-potency agents.Dystonias(otherthan laryngospasm) should be treated with 1-2 mg of benztropine (Cogentin) IM. dilated pupils and elevated heart rate. 2. Drug-Induced Parkinsonian Syndrome a. The patient may require long-term anticholinergic medication to control the dystonia. induce involuntary movements known as extrapyramidal side effects. This is similar to patients withidiopathic Parkinson’s disease. tongue.the dose of neuroleptic may need decreasing. In severe cases. 2. blurry vision. Anticholinergic Side Effects 1. Acute Dystonia a. E. eyes (oculogyric crisis). especiallylow-potency agents. typically occurring within 10-14 days after initiation ofthe neuroleptic. mask-like facies.
produce tardive dyskinesia. Patients who require continued neuroleptic therapy should be switched to an atypical agent or clozapine (if severe). and there is an incidence of 3% per year with typical agents. Neuroleptic Malignant Syndrome (NMS) 1. which are manifest by difficulty remaining still and excessive walking or pacing. blinking. F. with the exception of clozapine. 7. Tardive dyskinesia is an involuntary movement disorder involving the tongue. is also effective. G. toes. but tardive dyskinesia can be debilitating in severe cases. mouth. amantadine. . 5. Akathisia a. 2. d. sucking movements. All neuroleptics. Most patients have relatively mild cases. The dopamine releasing agent. grimaces and spastic facial distortions. smacking and licking of the lips. NMS is a rare idiosyncratic reaction. All neuroleptics. and other body parts. fingers. Tardive Dyskinesia (TD) 1. The risk of tardive dyskinesia withatypicalantipsychotics is substantiallydecreased compared to typical agents. tongue protrusion. The risk of tardive dyskinesia increases with the duration of neuroleptic exposure. When tardive dyskinesia symptoms are observed.Drug-induced Parkinsonism istreatedbyadding an anticholinergic agentsuchasbenztropine (Cogentin) or trihexyphenidyl (Artane).Parkinsonian symptoms may also improve with a lower dose of neuroleptic or after switching to a low-potency agent such as thioridazine or an atypical agent. 4. 3.Akathisia may respond to the addition of an anticholinergic agent. Tardive dyskinesias do not always improve with discontinuation or lowering of the dose of neuroleptic. the offending drug should be discontinued. c. b. 6.b. 4. which can be fatal. Tardive dyskinesias are characterized bychewing movements.butmoreoften. Benzodiazepines such as diazepam are used for refractory cases. Antiparkinsonian drugs are of no benefit for tardive dyskinesias and may exacerbate symptoms. Akathisia is characterized by strong feelingsofinner restlessness.a beta-blocker such as propranolol is required in the dose range of 10-40 mg tid or qid.
Some atypical antipsychotics are associated with marked elevation of lipids and blood glucose. H. mesoridazine.Orthostatic hypotension is especially common with low-potency agents such as chlorpromazine. Sexual Side Effects 1. altered mental status. WeightGain. Ziprasidone may increase the QT interval. The IM form of ziprasidone does not have this effect on the QT interval. or pimozide. Cardiac conduction delays can occur with thioridazine. which can result from treatment with clozapine and olanzapine. Dopamine receptor (D2) blockade can lead to elevation of prolactin with subsequent gynecomastia. Alpha-1 adrenergic blockade results in orthostatic hypotension which may be serious and can lead tofalls and injury. It is more common with low-potencyagents. along with supportive treatment and medications such as amantadine. galactorrhea. L. Sedation. A fasting glucose and lipid profile should be obtained every 3-6 months for patients on atypical antipsychotics. I. M. 3. Laboratory tests often reveal an elevated WBC. Some data suggests these adverse effects are more common with clozapine and olanzapine and infrequent with ziprasidone.thioridazine or clozapine. bromocriptine. Hyperlipidemiaand DiabetesMellitus 1. CPK. Patients should be advised to get up slowly from recumbent positions. Treatment involves discontinuing the neuroleptic immediately. and dantrolene. compared to high-potency agents. but this effect does not appear to be clinically significant. Cardiac Toxicity. Neuroleptic sedation is related to blockade of H-1 histamine receptors. such as haloperidol. fever. and autonomic instability. J. Blockade oftheserotonin 2C and histamine receptors may result in weight gain.suchaschlorpromazine. Orthostatic Hypotension. may produce NMS. Antipsychotics may produce a wide range of sexual dysfunction. 2.Bedtimeadministration will often reduce daytime sedation. . NMS is characterized by severe muscle rigidity. The risk of NMS with atypical antipsychotics is substantially decreased. 2.with the exception of clozapine. and liver transaminases. 2. Thioridazine hasthe greatesteffecton QTprolongation and should be used with caution. Patients may require treatment in an intensive care unit.and menstrual dysfunction. K.
Retrograde ejaculation. Photosensitivity is especially common with low-potency agents. Risperidone has an atypicalside-effect profile with minimal extrapyramidal symptoms at lower doses (up to 4-6 mg). Retinitis Pigmentosa. Most cases develop during the third and fourth weeks of treatment. 2. Clozapine is unique in that it does notproduce extrapyramidal symptoms. Treatment should include switchingto anotherclassofantipsychotic drug after a drug-free interval. Atypical Neuroleptics A. Irreversible blindness can rarely occur with a dose of thioridazine greater than 800 mg per day. Photosensitivity. B.tachycardia. At doses above 6 mg per day. clozapine must be discontinued. Clozapine (Clozaril)is a dibenzodiazepine derivative and is considered an atypical antipsychotic agent. rarely. 4. The risk of seizures are increased at dosages above 600 mg per day. Patients should be advised to use sunscreen. followed .and inhibition of orgasm are also common side effects. Risperidone (Risperdal) 1. Clozapine causessedation. or NMS. VI. 3. erectile dysfunction. Clozapine is associated with a 1% incidence of agranulocytosis. which can be fatal. N. Antipsychotic agents often cause photosensitivity and a predisposition to sunburn. Eosinophilia (>4000/mm3) may be a precursor of leukopenia. Cholestatic jaundice is usuallyreversible after discontinuation of the medication. O. P. or cannot tolerate.weightgain. Clozapine should be interrupted until count is below 3000/mm3. When white blood cell counts drop below 3 x 1012/liter. the incidence of EPS increases significantly. 2. Fatigue and sedation are the most common side effects. 1. There is no significant elevation of prolactin or subsequent side effects.Weeklymonitoring of the WBC is recommended for the first six months of treatment and every two weeks thereafter. Clozapine is used for the treatment of patients who have not responded to. excess salivation (sialorrhea). The effective dosage range is 2-8 mg/day.3. tardive dyskinesia. and. other neuroleptics. respiratory arrest in conjunction with benzodiazepines. Cholestaticjaundiceisararehypersensitivity reaction that is most common with chlorpromazine. such as chlorpromazine.orthostatic hypotension.
caution should be exercised in patients with pre-existing increased QT interval (from medications or cardiac disease). Ziprasidone (Geodon) 1. nausea. Ziprasidone IM (Geodon IM) is available and can be given 10 mg q 2-4 hours or 20 mg q 4 . Less frequent side effectsinclude weightgain. nausea. The typical starting dose is 10 mg/day. There isno evidence ofhemotoxicity. and tremor. Olanzapine has an atypical side-effect profile with a very low incidence of extrapyramidal symptoms. although some patients mayrequire higher doses. akathisia. Ziprasidone can increase QT interval. leadingtogynecomastia. Quetiapine (Seroquel) 1. Olanzapine (Zyprexa) 1. No titration isrequired. Ziprasidone has an atypical side effectprofile witha verylowincidence ofextrapyramidal symptoms. Risperidone can elevate prolactin.weight gain. Quetiapine is an atypical neuroleptic with a very low incidence of EPS. abdominal pain. These patients should have a baseline ECG. 3. and postural hypotension are the most common side effects. Side effects include orthostatic hypotension. Initial dose is 25-50 mg bid. Agranulocytosis has not been reported. C. somnolence. The effective dose range is 5-20 mg/day. The effective dose range isbetween 40-80 mg bid. E.orthostatic hypotension. 3. D. Sustained prolactin elevation is not observed. dry mouth. The incidence of tardive dyskinesia is low. Dyspepsia. Most common side effects include drowsiness. or effects on lipids and glucose. Initial and periodic eye exams (with slit lamp) are recommended because of the occurrence of cataracts in very high dose animal studies.by weight gain and orthostatic hypotension. 2. which is titrated every 1 or 2 days to a total daily dose of 400-600 mg (given bid or tid). and insomnia. Prolactin elevation can occur.galactorrhea and disruption of the menstrual cycle. Dizziness. 4. and weightgain. Olanzapinelevelsmaybedecreased bytobacco use or carbamazepine. Dose reductions should be made in the elderly. While there are no reports linking this to cardiac arrhythmias. 3. Dosage should be reduced in the elderly. and dry mouth may also occur. 2. 2.
but they may be given prophylactically in high-risk patients. Somnolence is more common with the IM form. Effective dose is 15-30 mg po per day. Anticholinergic and Antiparkinsonian Agents A. and akathisia. B. not to exceed 40 mg/day. Indications 1. Aripiprazole has an atypical side effect profilewithaverylowincidence of extrapyramidal symptoms. Antiparkinsonian agents are usually initiated when a patient develops neuroleptic-related extrapyramidal side effects. which often requires addition of a beta-blocker. Anticholinergic and antiparkinsonian agentsareusedtocontroltheextrapyramidal side effects of antipsychotic agents. including acute dystonic reactions.Aripiprazole is expected to be available in 2003 or 2004. Anticholinergics are drugs of choice for acute dystonias and for drug induced Parkinsonism. This agent is a dopamine autoreceptor agonist and post-synaptic D2 receptor antagonist. The anticholinergic agent should be tapered and discontinued after one to six months if possible. 3. Anticholinergic agents are less effective for drug-induced akathisia.hours. QT prolongation has not been observed with the IM formulation. neuroleptic induced Parkinsonism. Classification of Anticholinergic/Antiparkinsonian Agents Name Benztropi ne Biperiden Trade Name Cogentin Akineton Class Anticholin ergic Anticholin ergic Anticholin ergic Antihista mine/ Anti cholinergic Dopamine/ Agonist Dose 1-2 mg bid-tid orally or 1-2 mg IM 2 mg bid-tid orally or 2 mg IM 2-5 mg bid-qid 25-50 mg bid to qid or 25 50 mg IM 100-150 mg bid Trihexy phenidyl Diphenhy dramine Amantadi ne Artane Benadryl Symmetrel . giving it a uniquemechanismofaction. Aripiprazole (Abilify) 1. VII. 2. Aripiprazole has a low incidence of weight gain and no effect on QT interval.Intramuscular injections of anticholinergic agents are most effective for rapid relief. F. 2.
4. Side Effects of Anticholinergic Agents a. The most common side effects resultfrom peripheral antichoinergic l blockade:drymouth,constipation, blurry vision, urinaryhesitancy, decreased sweating, increased heart rate, and ejaculatory dysfunction. b. Acentral anticholinergic syndrome occurs with high doses, or when the agent is combined wthotheranticholinergicmedications. i The syndrome is characterized by confusion, dry flushed skin, tachycardia,and pupillarydilation. In severe cases, delirium, hallucinations, arrhythmias, hypotension, seizures, and coma may develop. c. Anicholinergicdrugsarecontraindicated t in narrow angle glaucoma and should be used cautiously in prostatic hypertrophy or cardiovascular disease. d. Amantadine does not have anticholinergic side effects; however, amantadine may causenausea,insomnia,decreased concentration,dizziness, irritability, anxiety,and ataxia.Amantadine is contraindicated in renal failure. Antidepressants Indications forAntidepressant Medication. Unipolar and bipolar depression, organic mood disorders, anxietydisorders (panic disorder, generalized anxiety disorder, obsessive-compulsive disorder, social phobia), schizoaffective disorder, eating disorder, and impulse control disorders. II. Classification of Antidepressants A. Selective-Serotonin (5HT) Reuptake Inhibitors. Fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), citalopram (Celexa), escitalopram (Lexapro). B. Serotonin/Norepinephrine Reuptake Inhibitors. Heterocyclics (TCAs), venlafaxine (Effexor) C. Norepinephrine/Dopamine Reuptake Inhibitors. Bupropion (Wellbutrin). D. MixedSerotoninReuptakeInhibitor/Serotonin Receptor Antagonist. Trazodone (Desyrel), nefazodone (Serzone). E. Alpha-2 Adrenergic Antagonist. Mirtazapine (Remeron) F. Monamine Oxidase (MAO)Inhibitors. Phenelzine,tranylcypromine,isocarboxazid. III. Clinical Use of Antidepressants A. All antidepressants have been shown to have equivalent efficacy. The selection of an agent depends on past history of response, anticipated I.
tolerance to side effects, and coexisting medical problems. B. Once a therapeutic dose is reached, symptom improvementtypicallyrequires 3 to 6 weeks. TCAs and bupropion have the narrowest therapeutic index and presentthegreatestrisk in overdose. C. If no significant improvement is seen after an adequate trial (4-6 weeks), then the dosage should be increased or one may switch to a medication in another antidepressant class. Alternatively, an augmenting agent such as lithium should be added. D. When psychoticsymptoms accompany severe cases ofdepression,concomitant antipsychotic medication is usually required and should be discontinued when the psychosis abates. E. Patients with three episodes of major depression should be placed on long-term maintenance treatment. IV. Side Effects A. Cardiac Toxicity 1. Tricyclic antidepressants may slow cardiac conduction, resulting in intraventricular conduction delay, prolongation of the QT interval, and AVblock.Patients withpreexisting conduction problemsarepredisposed to arrhythmias. Therefore, TCAs should not be used in patients withconduction defects, arrhythmias, or a history of a recent MI. 2. SSRIs, venlafaxine, bupropion, mirtazapine, and nefazodone have noeffectsoncardiacconduction. B. Anticholinergic Adverse Drug Reactions. Dry mouth, blurred vision, constipation, and urinary retention. C. Antihistaminergic Adverse Drug Reactions. Sedation, weight gain. D. Adverse Drug Reactions Caused by Alpha-1 Blockade. Orthostatic hypotension,sedation,sexual dysfunction. E. Serotonergic Activation.GI symptoms (nausea,diarrhea),insomniaorsomnolence, agitation, tremor, anorexia, headache, and sexual dysfunction can occur withSSRIs,especiallyearlyin treatment. F. MAO inhibitors. The most common adverse drug reaction is hypotension. Patients are also at risk for hypertensive crisis if foods high in tyramine content or sympathomimetic drugs areconsumed. Despite the infrequent use of MAO inhibitors, they remain very important forthetreatmentofrefractorydepression.
Commonly Used Antidepressants Drug Recommended dosage Comments
Secondary Amine Tricyclics Class as a whole: Side effects include anticholinergic effects (dry mouth, blurred vision, constipation) and alpha-blocking effects (sedation, orthostatic hypotension, cardiac rhythm disturbances). May lower seizure threshold. Desipramine(Norpramin, Initial dosage 25-50 mg qhs, generics) average dose 150-250 mg/d, Mayrequire dose of 300 mg/d. [10, 25, 50, 75, 100, 150 mg] Protriptyline(Vivactil) Mayhave CNS stimulant effect; best taken in morning to avoid insomnia.
Initialdoseof5mgqam increasing Low sedation, avoid bedtime to 15-40 mg/d in bid dosing dosing. [5, 10 mg] Initial dose 25 mg qhs, increasing Sedating. to 75-150 mg/d; monitor levels to achieve serum level between 50-150 ng/mL. [10, 25, 50, 75 mg]
Tertiary Amine Tricyclics Class as a whole: Anticholinergic effects and orthostatic hypotension may be more severe than with secondary amine tricyclics. All are contraindicated in glaucoma and should be used with caution in urinary retention and cardiovascular disorders. Amitriptyline (Elavil, Initial dose of 25-50 mg qhs generics) increasing to 150-250 mg/d. May be given as single hs dose. [10, 25, 50, 75, 100, 150 mg] CIomipramine(Anafranil) High sedation.Highanticholinergic activity.
Initial dose of 25-50 mg qhs Relativelyhighsedation,anticholinergic increasing to 150-250 mg/d; activity, and seizure risk. may be given once qhs [25, 50, 75 mg] High sedation, often used as a hypnotic at a dosage of 25-150 mg qhs. Relatively high sedation. Also used to treat enuresis.
Doxepin (Sinequan, Initial dose of 25-50 mg/d, Adapin) increasing to 150-300 mg/d. [10, 25, 50, 75, 100, 150 mg] Imipramine (Tofranil, 75 mg/d in a single dose qhs, generics) increasing to 150 mg/d; max 300 mg/d. [10, 25, 50 mg] Tetracyclic Mirtazapine(Remeron)
15 mg qhs initially increasing Highly sedating with average to 30-45 mg qhs over days of 2 kg weight gain in six weeks. to weeks [15, 30 mg] Minimaleffectonhepatic enzymes. Sedating. Substantial risk of seizures; maculopapular rash in 3-10%.
Maprotiline (Ludiomil, 75 mg qhs initially, Usual generics) effective dose 150 mg/d, max 225 mg/d. [25, 50, 75 mg]
250 mg] hypotension. Max 600 mg/d. gradually to dose of 300-600 Orthostatic hypotension. activation. drymouth. Significant up to 300 mg/day [25.50.5 mg bid initiallyincreasing (Effexor. inhibition of CYP1A2 100 mg] Moderate sedation and dry mouth. Longest half-life of any antidepressant (2-9days). 50.5.Drug Amoxapine(Asendin) Recommended dosage Comments Initial dosage 25-50 mg qhs. vision somnolence. Maybe associated with tardive increase to 200-300 mg/d dyskinesia. 100 mg bid initially increasing Wellbutrin SR) to 100 mg tid over 5 days. [25.somnolence. [100. Slow release (SR): begin with 100-150 mg qd for 3 days. Common sideeffects: Nausea. 100 mg] [SR: 100. 200 mg] Trazodone(Desyrel) 50-100 mg qhs initially increasing Rare association with priapism. Fluoxetine(Prozac) 10-20 mg/d initially. insomnia. Minimal sedation. 150 mg] Selective-Serotonin Reuptake Inhibitors (SSRIs) Class as a whole: Common side effects include sexual dysfunction. activation. or inhibition of hepatic enzymes.5. to max of 200 mg/d [50. . 150. headache. 30. 100. may require up to 80 mg/day for OCD and bulimia [10. 37.Discontinue 2months before pregnancy.Elderlystarting dosage. 100 mg] [XR: 37. activation. 100] Bupropion (Wellbutrin. insomnia. 150. 40 mg] Citalopram(Celexa) Escitalopram(Lexapro) Sertraline (Zoloft) 20-60 mg/d [20. Mild hypertension. tremor. dry mouth. Significant inhibition of CYP2D6 50 mg hs initially. Significantinhibition ofCYP2D6. Paxil 20 mg hs initially. Significant inhibition of CYP2D6. neurolepticmalignant if necessary. or inhibition of hepaticenzymes. 150. vomiting. increasing as needed Minimal sedation. 10 mg/d [10. mg] Miscellaneous Nefazodone(Serzone) 50-100 mgbidinitially. Minimal or no inhibition ofhepaticenzymes. dry mouth. max of CR [extendedrelease]) 80 mg/d. Venlafaxine 37. anxiety. headache. 20. 100 or inhibition ofhepatic enzymes. nausea. 75. nausea. 300 sedating. Effexor XR) to 150-225 mg/day in divided dose. 100. 50. Agitation. mild sedation. minimal sexual side-effects or inhibition of hepatic enzymes. constipation. increasing Headache. anorexia. blurred to 150-300 mg bid. Minimal sedation. anxiety. Paroxetine (Paxil. 75. sexual dysfunction. Extended release (XR): 37. postural 200. increasing to 150 mg bid over 4-7 days [75. Highly mg/day [50. insomnia.5-75 mg/day increasing to 150-225 mg/day [25. headache. taken in AM. galactorrhea. dizziness. 40 mg] 10-20 mg qd 50 qd. syndrome. Good choice if sexual side effects from other agents. 20 mg tablets / 5 mg/mL soln] Fluvoxamine(Luvox) May be activating. then increase Moderate sedation.
B. and cyclothymia. . but a trial of four to six weeks should be completed before evaluating efficacy. and cyclothymia. Mood stabilizers are less effective for bipolar depression. Serum levels. or mental retardation.Theaverage doseisbetween 1500-3000 mg/day.in addition to being an antimanic agent. C. C. 2. Lithium(Eskalith.Mood Stabilizers I. Depakote ER has 80-90% bioavailabilitycompared to Depakote.Eskalith CR. 3. These agents are sometimes effective for impulse control disorders. Lithonate) A. 4. Valproic acid is effective for bipolar disorder. B. III. B. platelet count. Elderly patients require doses of approximatelyhalf that of younger adults. Regular and slow-release forms of lithium carbonate are available and either form may be given twice daily initially switching to once daily dosing after several weeks. Valproic acid is more effective in rapid cycling and mixed state episode bipolar disorder than lithium. They are effective for acute mania and for prophylaxis of mania and depression in bipolar disorders. Mood stabilizers are the drugs of choice for bipolar disorder. Lithium. CBC.schizoaffective disorder. schizoaffective disorder. However. and PT/PTT should be obtained weekly during the first month of treatment. possesses modest but significant antidepressant properties.Divalproex is initiated at a dosage of 20 :g/kg for rapid stabilization of mania. mental retardation and aggressive behavior. Healthy young adults can usually tolerate300-600 mg of lithium carbonate. Treatment Guidelines 1. Valproic acid has become the mood stabilizer of choice due to its favorable side-effect profile and lower toxicity in overdose compared to lithium or carbamazepine. Depakote ER (extended release) tablets (500 mg) allow for once a day dosing. D. lithium is less effective than valproate (Depakote) in rapid cycling mania. Valproate usually requires two weeks to take full effect. Steady state levels can be measured in 2-3 days. This roughly corresponds to 500 mg tid or 750 bid with titration up to a serum level of 50-125 mg/mL. II. Divalproex (Depakote) is the best toleratedformofvalproate. dementia. Valproic Acid (Depakote) A. It is also used for impulse control disorders and aggression in Cluster B personality disorders. Indications for Mood Stabilizers A.
Lithium toxicityis manifest bycoarse tremor. G.20 mMol/L).2 mMol/L K. Two weeks are required for effect. such as ibuprofen or aspirin and ACE inhibitors. but continues to take lithium. Serum lithium levels are measured 12 hours after the preceding dose of lithium. are initiated. such as tremor. A patient who cannot eat and drink normally should temporarily discontinue lithium.twice daily at the start of therapy. and an ECG in patients over 40 years or with pre-existing cardiac disease. Side effects. may be reduced by using divided doses. 3.electrolytes. A reduction of lithium dose may be required. L. Common side effects of lithium include polyuria. confusion.80 to 1. nausea) may be reduced by giving the medication with meals or by switching to a sustained release preparation. Lithium levels should be carefully monitored. vomiting.andarrhythmias. Nonsteroidal anti-inflammatory drugs. free T4 levels.seizures.incontinence. Serum levels should be kept between 0. A reduction of lithium dose may be required.ataxia. Toxicity may occur when a patient becomes ill and ceases to eat and drink normally.finetremor. F.creatinine. Tremor is most common in the hands. elevate the plasma lithium level. Diabetes insipidus may result from lithium administration. thirst. such as chlorothiazide (Diuril). I. fasting blood sugar. The dose is increased over seven to ten days until the plasma level is 0.persistent headache.8-1. or a single daily dose of lithium. Serum levels must be drawn weekly for the first one to two months. Side Effects 1. J. edema.Itpresents withpolyuria and polydipsia.stupor. E. Laboratoryevaluation prior to beginning treatment with lithium should include blood urea nitrogen. Serumcreatinine and TSH are monitored every 6 months. 2.Treatment consists of amiloride administration. Lithium levels rise 20-25 percent when diuretics. weight gain.mild nausea (especially if the drug is not taken with food). slow-release formulations. . The usual adult dosage ranges from 600-2400 mg/day. H.20 mEq/L (0. and diarrhea. D.80-1. and the drug should be continued for four to eight weeks before evaluating efficacy. Tremor is treated bylowering the dosage or byadding low-dose propranolol (10-40 mg tid-qid). then every two to four weeks. Gastrointestinal distress(diarrhea. TSH. slurred speech.
which usuallyresponds to discontinuation of lithium.000 mcL. Cardiac side effects include T-wave flattening or inversion and rare arrhythmias. confusion. At this time. B.Carbamazepine is dosed bid or tid to minimize side effects. Side Effects 1. 6. levels may be drawn less frequently.whichrequirediscontinuation of lithium. The most serious side effects ofcarbamazepineare agranulocytosis and aplastic anemia. Dermatological side effects include acne. usually between 11-15thousand. Lithium can induce or exacerbate psoriasis. 5. which occur at a frequency of 1 in 20. Obtain serum levels (target is 8-12 :g/mL) along with a CBC. Toxicity presents with emesis.5 mEq/liter. Seizures. but a therapeutic trial should last at least four to eight weeks. EKG.000 cells/mcL. Carbamazepine (Tegretol) A. diarrhea. CBC with differential and platelets. Carbamazepine is used in patients whodonotrespondtolithium. liver function tests and electrolytes weekly for a month. 5. liver function tests. 3.orifthe absolute neutrophil count drops below 1. IV.in doses of 5-20 mg per day with frequent monitoring of lithium and potassium levels. 7. Carbamazepine induces its own metabolism and carbamazepine levels will decline between three and eight weeks.000.isfrequently observed and requires no treatment. or if the platelet count drops below 100. 4. 4. C.Treatmentofoverdose may require hemodialysis. . Pretreatment Evaluations. Treatment Guidelines 1. the dosage mayneed tobeincreased to maintain a therapeutic blood level of 8-12 :g/mL.electrolytes. 2. Carbamazepine shouldbediscontinued if the total WBC count drops below 3. After the first month. Elevated WBC count. creatinine and physical examination. Hypothyroidism may result from lithium andis treated withlevothyroxine. and cardiac arrhythmias.5 mEq/liter. 8. The WBC should be monitored more frequently if the white count begins to drop. 2.500 cells/mcL. coma and death may occur at levels above 2. which can be controlled with benzoyl peroxide or topical antibiotics. Carbamazepine requires two weeks to take effect. ataxia. Lithium toxicity may occur when levels exceed 1.
Gastrointestinal distress (nausea and vomiting) is the most common side effect.doxycycline. Mild elevations in liver function tests are seen in most patients and this does not require discontinuation of the drug. D. 5. Valproateismore benign in overdose than lithium or carbamazepine. a severe dermatologic condition. Serum levelsare decreased byclomipramine and phenytoin.Stevens-Johnson syndrome begins with widespread purpuric macules. Carbamazepine may also cause ataxia.especialyifaccompanied by confusion. corticosteroids. Stevens-Johnson syndrome. liver function tests.theophylline. 2. Sedation is common and usually abatesinthefirstfewweeks. Carbamazepine is more benign in overdose than lithium. If this occurs the carbamazepine dose should be decreased to achieve serum levels of 8-12 :g/mL.Hepatitis andpancreatitis are rarecomplications and usually occur during the first several months. E. 4. Carbamazepine decreases serum levels ofacetaminophen. thyroid supplements. Elevated ammonia may. valproate.000. 4. and these symptoms often improve with coadministration with food or after switching to an enteric coated preparation such as Depakote. Pretreatment Evaluation. Mild elevations of liver function occur in many patients and require no special treatmentexceptfrequent l monitoringofiverenzy mes. PT/PTT. . 3. CBC. phenytoin.methadone. however. 5. 6. confusion. epidermis and severe constitutional symptoms.cyclosporine. which may require discontinuation of carbamazepine. Hepatitis may rarely occur. is a rare side effectofcarbamazepine and requires immediatediscontinuation oftherapy. and tremors (usually with high doses or toxicity). Physical examination. Side Effects 1. and ethosuximide. warfarin.3. be an indicator of severe l hepatotoxicity.antipsychotics.Thrombocyopenia t israreand mayrequire discontinuation of the drug if levels drop below 100. platelets. Elevation of serum ammonia is a rare complication and is often benign. benzodiazepines. leading to epidermolysis necrosis with erosion of mucus membranes.oral contraceptives.
2. A small number of controlled studies support the effectiveness of gabapentin in mood disorders. irritability. It appears to have some efficacy for mixed episodes and rapid cycling. Gabapentin has been effective primarily as an adjunctive treatment to other mood stabilizers and/or antidepressants. nauseaand vomiting and dizziness. Therapeutic effects can be seen in 2-4 weeks. Lamotrigine is an anticonvulsant. Impaired renal function is nota contraindication togabapentin. prompting some clinicians to use it in the treatment of resistant unipolar depression. 3. 2. ataxia. fatigue. D. Starting dose is 300 mg q day with titration up to an average daily dose of 900-1800 mg q day in divided doses. Some studies have used up to 3600 mg/day. . the dosage should be reduced in patients with impaired renal function. It also appears to be more effective in the treatment of depression compared to other mood stabilizers. Side Effects 1. Serum levels are not useful because no therapeutic window has been established. Gabapentin (Neurontin) A. Lamotrigine (Lamictal) A. Weight gain is an occasional side effect of gabapentin. VI. however. A small number of controlled studies support its effectiveness in mood disorders. Clinical experience suggests that it may be effective in the treatment of manic and depressive episodes. C.V. B. Renal function should be evaluated before initiating treatment because gabapentin is excreted unchanged renally. Given its short half-life. Treatment Guidelines 1. the time between doses should not exceed 12 hours. B. Lamotrigine may be effective in the treatment of manic and depressive episodes. The most common side effects are somnolence. Gabapentin has been reported to rarely cause anxiety. agitation and depression.
C. Lamotrigine has been successful as monotherapy and as adjunctive treatment to other mood stabilizers and/or antidepressants. It appears to be effective for mixed episodes and rapid cycling. D. Treatment Guidelines 1. Pre-treatment evaluation should include an assessment of renal and hepatic function because both are involved in its excretion. 2. The initial dosage is 25 mg qd, increased weekly to 50 mg/day, 100 mg/day, then 200 mg/day. Up to 400 mg may be required to treat depression. Dosing can be either once or twice a day. 3. Serum levelsare notuseful because the therapeutic window has not been determined. 4. Coadministrationwithotheraniconvulsants t can affect serum levels and should be used with caution. 5. Therapeutic effect may be seen in 2-4 weeks. E. Side Effects 1. The most common side effects are dizziness, sedation, headache, diplopia,ataxiaordecreasedcoordination. The side effect most likelyto cause discontinuation of the drug is rash (10%), which can be quite severe. Rashismostcommonwhenlamotrigine is initiated at higher doses when titration is rapid. 2. Lamotrigine has been reported to cause irritability, agitation, anxiety, mania and depression. 3. Carbamazepinewill lower lamotrigine levels and valproate will increase lamotrigine levels. VII. Topiramate (Topamax) A. Topiramate is a new anticonvulsant that is being studied for efficacy as a mood stabilizer. Uncontrolled studies indicate that topiramate may have efficacy in the treatment of mixed mania and rapid cycling thatis unresponsive to valproate or carbamazepine. B. Treatment Guidelines 1. The starting dose is 25-50 mg/day, increasing at increments of 25-50 mg per week to a target dose of 200-400 mg/day, given in single dose or bid. Therapeutic effects are seen in 2-4 weeks.
2. Topiramate is primarily excreted unchanged in urine and has no effect on liver enzymes. Plasma levels oftopiramate can be reduced up to 50% when combined with carbamazepine and to a lesser degree with valproate. Topiramate can reduce clearance of phenytoin and impair the efficacy of oral contraceptives. C. Side Effects 1. The most common side effects are sedation, dizziness, ataxia, vision problems, speech problems, memoryimpairment, and problems with language processing. 2. Unlike other mood stabilizers, topiramate does not cause weight gain and may promote weight loss. VIII. Tiagabine (Gabitril) A. Tiagabine is a new anticonvulsant that is being studied for efficacy as a mood stabilizer. Uncontrolled studies suggest that it may be useful as an adjunct to other mood stabilizers. Tiagabine may have some efficacy for chronic pain and anxiety. B. Tiagabine is hepaticallymetabolized, but it does not appear to induce hepatic enzymes. Tiagabine does not affect the metabolism of other medications. Clearance may be decreased up to60%whencombinedwithcarbamazepine, phenytoin, or phenobarbital. C. The initial dose is 4 mg/day, increasing by 4 mg at weekly intervals to 12 mg/day, given in single dose or bid. The typical maintenance dose for seizures is 24-32 mg/day given bid or qid. D. The most common side effects are dizziness, lack of energy, somnolence, nausea, nervousness, and tremor. IX. Oxcarbazepine (Trileptal) A. Oxcarbazepine isa newanticonvulsant that is being studied for efficacy as a mood stabilizer. Controlled studies suggest that it is effective in mania at doses between 900-2400 mg/day. B. The most common side effects are somnolence, dizziness, diplopia, ataxia, nausea, vomiting and rash.
X. Levetiracetam(Keppra)has beenapproved for treatment of partial seizures. Its efficacy for affective illness is unknown. Antimanic Agents Name Divalproex sodium Trade Name Depakote Dosage Forms 125, 250 or 500 mg 125 mg sprinkle cap sules Lithium car bonate Lithium car bonate, slow release Lithium ci trate Carbamaze pine Lithonate, Eskalith Lithobid, Eskalith CR Cibalith-S Tegretol, generics 300 mg 300 or 450 mg 8 mEq/5 mL 100 or 200 mg Liquid: 100 mg/5 mL Valproic acid Divalproex sodium ex tended re lease Gabapentin Lamotrigine Tiagabine Topiramate Depakene Depakote ER 250 mg 500 mg Dose Range 500-4000 mg in bid dosing 500-3000 mg in bid dosing 600-2400 mg 600-2400 mg Therapeutic Drug Levels 50-125 micro gm/mL 50-125 micro gm/mL 0.8-1.2 mEq/liter 0.8-1.2 mEq/liter
10-40 mL 400-1800 mg in bid- qid dosing 400-1800 mg in bid- qid dosing 500-3000 mg in bid dosing 500-4000 mg in a single dose 300-800 mg tid 100-400 mg 12-mg qd or in divided dose 200-400 mg qd or in di vided dose
0.8-1.2 mEq/liter 8-12 micro gm/mL 8-12 micro gm/mL 50-125 micro gm/mL 50-125 mcg/mL
Neurontin Lamictal Gabitril Topamax
100, 300, 400 mg 25, 100, 150, 200 mg 4, 12, 16, 20 mg 25, 100, 200 mg
not applicable not applicable not applicable not applicable
3. 2.5 10 Half-Life of Metabolites (hours) Alprazolam Chlordiazep oxide Xanax Librium 0. Benzodiazepines may produce ataxia. Indications. b. Benzodiazepines A. 1.25-2 tid/qid 25-50 tid/qid 6-20 30-100 . Allbenzodiazepines induce tolerance and are addictive. Long-acting agents. and dizziness. Short courses of treatment should be used whenever possible. 2 mg IM because it is well tolerated and effective in most patients. 3.suchasclonazepam and diazepam . The primaryindications for long-term treatmentare chronic anxietydisorders such as generalized anxietydisorder and panicdisorder. Benzodiazepines are contraindicated in pregnancy or lactation. Tolerance to sedative effects often occurs during the first few weeks of treatment. seizure disorders. insomnia. When benzodiazepines are discontinued. They are also effective adjunctive agents for agitated psychotic or depressive states. such as chronic obstructive pulmonary disease. 2. The 3-hydroxy-benzodiazepines (lorazepam. Acute agitation usually is treated with lorazepam (Ativan). Benzodiazepines are used for the treatmentofanxietydisorders. Miscellaneous Side Effects a. Sedation is the most common anduniversalsideeffectofbenzodiazepines. Side Effects 1. especially with high-potency agents (alprazolam) or short-acting agents (triazolam). Respiratorydepression can occur athigh doses. especially in combination with alcohol or respiratory disorders. the drug should be tapered slowly.Anterograde amnesiaiscommonafterbenzodiazepine use. Antianxiety Agents Name Trade Name Dose (mg) Dose Equivalence 0. B. oxazepam) have no active metabolites and are the agents of choice in patients with impaired liver function.are preferable for long-term treatment because they cause less withdrawal and require less frequent dosing.alprazolam. and alcohol detoxification. slurred speech. CognitiveDysfunction.Antianxiety Agents I.
The starting dose is 5 mg two to three times a day.Graduallyincrease to a maximum dosage of 60 mg per day over several weeks. Buspirone (BuSpar) A. B. see page 121.5–2 tid/qid 15-30 tid/qid 5-20 bid/tid 18-50 30-100 30-100 30-100 10-20 8-12 30-100 II. Indications 1. References References. Buspirone is a nonbenzodiazepine anxiolytic agent of the azaperone class. Side Effects 1. the most common side effects are nausea.25-2 bid/tid 7. C. Electroconvulsive Therapy . Buspirone is not addicting and has no withdrawal syndrome or tolerance.5 -30 bid 2-15 bid/tid 20-80 bid 0. Buspirone is generallywell tolerated. At least two weeks are required before clinical improvement occurs. Buspirone maybe added in a dosage of 15-60 mg/dayifa patienthas had a suboptimal response to a 3-6 week trial of an antidepressant. It does not produce sedation or potentiate the effects of alcohol. 2. dizziness. Many patients respond to a total dose of 30-40 mg per dayin two to three divided doses. Buspirone may also be an effective adjunctive agent in the treatment resistant depression. D.25 7. 2. Buspirone (BuSpar) is indicated foranxietydisorders.5 5 20 1 15 10 Half-Life of Metabolites (hours) Clonazepam Clorazepate Diazepam Halazepam Lorazepam Oxazepam Prazepam Klonopin Tranxene Valium Paxipam Ativan Serax Centrax 0. and insomnia. 2.Name Trade Name Dose (mg) Dose Equivalence 0.such as generaized l anxiety disorder. Dosage 1. headaches.
D. 2. chest X-ray. B. I. Electrical stimulation should . Electroconvulsive therapy is effective for major depressive disorder. is administered for anesthesia. compared to a 70% response rate for antidepressants. A short-acting barbiturate. bipolar affective disorder (to treat mania and depression). C. Indications A. routine laboratorytests (CBC.Electroconvulsive therapy (ECT) is a highly effective treatment for depression. and acute psychosis. A second psychiatrist. Pretreatment evaluation should include a complete a history and physical. Informed consent should be obtained 24 hours prior to the first treatment. can safely undergo ETC. with a response rate of 90%. such as methohexital. and brain CT scan. The patient should be NPO for at least eight hours and blood pressure. oxygen content. thyroid function). Pregnant women who are severely depressed. cardiac activity. 4. C. Muscle paralysis is then induced by succinylcholine. Electroconvulsive therapy may be usedasafirst-linetreatmentfor depression. 3. EKG. The seizure must last a minimum of 25 seconds and should not last longer than two minutes. and the electroencephalogram should be monitored. catatonic stupor. especially if associated with acute suicidal behavior or psychotic symptoms. A tourniquet (to prevent paralysis) is applied to one extremity in order to monitor the motor component of the seizure. Depression in Parkinson's disease responds to ECT with the added benefit of improvement of the movement disorder. must also examine the patient and document the appropriateness of ECT and the patient's abilityto give informed consent. II. Dose 1. and who want to avoid long-term fetal exposure to antidepressant medication. Electroconvulsive TherapyProcedure 1. If theseizurelastsless than 25 seconds. spinal X-ray series. B. not involved in the treatment of the patient. a rubber mouth block is then placed and an electrical stimulus is applied to induce the seizure. D. The duration ofthe seizure is monitored byEEGand byobservingtheisolated extremity. liver enzymes. electrolytes. After an airway has been established. Elderly patients tend to have a better response to ECT than toantidepressant medication. wait one minute and then stimulate again. Electroconvulsive TherapyEvaluation A.urinalysis.
A small numberofpatients complain ofpersistent memorydifficulties after several months. A minimum of six treatments are usuallyrequired (common course is8-12 treatments). D. and the complication rate is comparable to that of anesthesia alone. Up to twenty treatments may be necessarybefore maximum response is attained. Diagnostic and Statistical Manual of Mental Disorders. Infrequently. 1994. Maintenance Electroconvulsive Therapy A. Side Effects of Electroconvulsive Therapy A. B.ccspublishing. 4th edition. Some patients may require long-term treatment. and it usually resolves with analgesics in a few hours.. Treatments are given two to three times per week. References American Psychiatric Association. Washington. maintenance ECT may be required for up to six months after the end of the initial series of 8-12 treatments. 2. Treatments are given weekly for one month and then graduallytapered to one treatment every four to five weeks. Loss of recent memory usuallyresolves within a few days to a few weeks.be discontinued after three failed attempts. IV. V. If seizures exceed two minutes. Additional references may be obtained at www. B. The first three are often performed with bilateral electrode placement.and recent MI. 3. Headache is common after ECT. The procedure is very safe. III. American Psychiatric Association. intravenous diazepam is used to terminate the seizure. recentstroke.com/ccs . The prognosis is similar to that of major depression. MemoryLoss.C.Retrograde and anterograde amnesia of the events surrounding the treatment is common. ContraindicationstoElectroconvulsive Therapy include intracranial mass.
0 Alzheimer's disease on Axis III) .8 Alcohol-Induced Mood Disor der 291.00 Opioid Dependence 305.xx Dementia of the Alzheimer's Type.10 Uncomplicated 290.8 Alcohol-Induced Anxiety Dis order AMPHETAMINE (OR AMPHETAMINE-LIKE)-RELATED DISORDERS 304.60 Cocaine Abuse OPIOID-RELATED DISORDERS 304.Selected DSM-IV Codes ATTENTION-DEFICIT AND DISRUPTIVE BEHAVIOR DISORDERS 314.0 Uncomplicated 290. With Early Onset (also code 331.0 Alzheimer's disease on Axis III) . Hypnotic.90 Alcohol Dependence 305.40 Sedative.1 Personality Change Due to.10 Sedative.80 Polysubstance Dependence . Hypnotic.70 Amphetamine Abuse COCAINE-RELATED DISORDERS 304.40 Amphetamine Dependence 305. With Late Onset (also code 331.xx Attention-Deficit/Hyperactivity Disorder .. OR ANXIOLYTIC-RELATED DISORDERS 304.01 Combined Type . or Anxio lytic Abuse POLYSUBSTANCE-RELATED DISORDER 304.01 Predominantly Hyperactive-Impulsive Type DEMENTIA 290. or Anxio lytic Dependence 305.00 Predominantly Inattentive Type .20 Cocaine Dependence 305.xx Dementia of the Alzheimer's Type. [Indicate the General Medical Condition] ALCOHOL-RELATED DISORDERS 303. HYPNOTIC-.xx Vascular Dementia .00 Alcohol Abuse 291.40 Uncomplicated MENTAL DISORDERS DUE TO A GENERAL MEDICAL CONDITION NOT ELSEWHERE CLASSIFIED 310..50 Opioid Abuse SEDATIVE-.
xx Adjustment Disorder . .82 With Hallucinations 298.3x Recurrent 300.81 Posttraumatic Stress Disorder 308.4 Dysthymic Disorder 311 Depressive Disorder NOS BIPOLAR DISORDERS 296.01 Panic Disorder Without Ago raphobia 300.0x Single Manic Episode .90 Undifferentiated Type .40 Most Recent Episode Hypomanic .1 Anorexia Nervosa 307.3 Obsessive-Compulsive Disor der 309.SCHIZOPHRENIA AND OTHER PSYCHIATRIC DISORDERS 295.7 Most Recent Episode Un specified 296.3 Shared Psychotic Disorder 293..50 Eating Disorder NOS ADJUSTMENT DISORDERS 309.xx Major Depressive Disorder .80 Bipolar Disorder NOS 293..02 Generalized Anxiety Disorder EATING DISORDERS 307. .20 Catatonic Type .23 Social Phobia 300.51 Bulimia Nervosa 307.2x Single Episode .83 Mood Disorder Due to.21 Panic Disorder With Agora phobia 300.60 Residual Type 295.22 Agoraphobia Without History of Panic Disorder 300.6x Most Recent Episode Mixed .xx Psychotic Disorder Due to.70 Schizoaffective Disorder 297.40 Schizophreniform Disorder 295..xx Bipolar I Disorder.81 With Delusions . [Indicate the General Medical Condition] ANXIETY DISORDERS 300.13 Cyclothymic Disorder 296.9 Psychotic Disorder NOS DEPRESSIVE DISORDERS 296.xx Schizophrenia .0 With Depressed Mood .29 Specific Phobia 300.5x Most Recent Episode Depressed ..89 Bipolar II Disorder 301.30 Paranoid Type .4x Most Recent Episode Manic .8 Brief Psychotic Disorder 297.3 Acute Stress Disorder 300.1 Delusional Disorder 298.10 Disorganized Type .
22 Schizotypal Personality Disor der 301.82 Avoidant Personality Disorder 301.83 Borderline Personality Disor der 301.81 Narcissistic Personality Disor der 301.3 .50 Histrionic Personality Disor der 301.20 Schizoid Personality Disorder 301.9 With Anxiety With Mixed Anxiety and Depressed Mood With Disturbance of Con duct With Mixed Disturbance of Emotions and Conduct Unspecified PERSONALITY DISORDERS 301..7 Antisocial Personality Disor der 301.24 .0 Paranoid Personality Disorder 301.9 Personality Disorder NOS .28 .4 .4 Obsessive-Compulsive Per sonality Disorder 301.6 Dependent Personality Disor der 301.
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