Psychiatry History Taking

Third Edition

Alex Kolevzon, MD
Fellow in Child and Adolescent Psychiatry
Mount Sinai School of Medicine
New York, New York

Craig L. Katz, MD
Clinical Assistant Professor of Psychiatry
Director, Psychiatric Emergency Department
Mount Sinai School of Medicine
New York, New York

Current Clinical Strategies Publishing

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Evaluation of the Psychiatric Patient
I. Establishing rapport A. The first step in interviewing a psychiatric patient is to establish rapport and create an environment where the patient feels comfort­ able disclosing personal information. The examiner should begin by introducing him­ self and stating the purpose of the interview. B. The examiner should be caring, competent, and concerned about helping. Good listen­ ing will often provide the patient with confi­ dence in the examiner and facilitate trust and openness. II. Interview structure A. The structure of the clinical interview does not usually follow a rigid format. It is best to guide the patient through their psychiatric history by listening to specific cues the pa­ tient provides and responding with appropri­ ate questions and comments. B. History taking typically begins with open-

ended questions, which allow the patient to tell the story in his own words. Directed, or more close-ended questions, are used later to elicit specific details when the examiner requires further elaboration. III. Observation A. How the patient speaks and behaves is equally important as what they say. Assess­ ment begins with simple observation of the patient. Personality characteristics and the way in which patients view themselves and interact with their environment are also considered with the presenting complaint. B. The emphasis of the clinical interview is to establish a working diagnosis based on Diagnostic Criteria (DSM-IV-TR) and to develop an appropriate treatment plan. Much of the interview is focused on asking specific questions designed to reveal the presence of symptoms consistent with mood, psychotic, and anxiety disorders. IV. Mental status exam A. The mental status exam is an assessment that provides a common language to de­ scribe patient characteristics. The interview provides data that help to elucidate elements of the patient’s presenting complaints and history. The mental status of the patient may change with each exam, and results are relevant only to the time of the interview. B. When discussing an impression of a patient, it is useful to begin by summarizing the mental status exam. V. Written format A. The psychiatric report presents the history in a specific written format. The report includes a proposed multiaxial diagnosis and summa­ rizes the clinical impression and manage­ ment recommendations. B. Suggestions for further work-up are also included, such as laboratory testing, neuro­ logical examinations, diagnostic testing, and gathering information from family, friends, and other health-care providers. Interviewing Techniques
Technique Reflection Facilita­ tion Silence Confron­ tation Clarifica­ tion Transition Reinforce­ ment Interpreta­ tion Summa­ tion Explana­ tion Description Empathic repetition of patient’s words to show understanding Nodding, saying yes, or uh-huh, to help con­ tinue the interview Allowing the patient time to think or cry Challenging the patient by pointing out something overlooked or denied Eliciting details and addressing contradic­ tions Switching topics Giving positive feedback to encourage dis­ closure Offering insight to facilitate awareness Summarizing information to confirm under­ standing Explaining the treatment plan and answering questions

Adapted from Psychiatry Essentials: A Systematic Review, Hanley & Belfus Inc, 2001

The Psychiatric History
Identifying data: Patient’s name, age, gender, marital status, occupation, current living situation, language, and ethnic background. Chief complaint: Provide the reason that the patient is seeking care using the patient’s own words in quotation marks. History of present illness: Document current symptoms as described by the patient; date of onset, duration and course of symptoms. Obtain a chronological description of recent events leading up to the presentation, precipitating events, and any other psychosocial stressors. This section should include a psychiatric review of symptoms that assesses the presence of affec­ tive, psychotic, and anxiety disorders. Past psychiatric history: Past and current diagnoses; a detailed description of past illness, hospitalizations, and treatments. Include past problems with suicidal thinking and attempts. Substance abuse history: Alcohol, cocaine, heroin, marijuana, amphetamines, barbiturates, hallucinogens, and prescription medications, such as opioids or benzodiazepines. If alcohol use is present, screen for abuse or dependence with questions about attempts to cut down, anger, guilt, eye-openers, history of blackouts, shakes, sei­ zures, or delirium. Ask about the amount of sub­ stance used, money spent daily, weekly, or monthly. Ask about method of use, such as in­ haled, intranasal, or intravenous. Social history: Developmental history if rele­ vant, level of education, social history with atten­ tion to important relationships and family conflict; marital history, religion, occupational history, and history of violence or criminal activity. Details of past traumatic events; physical abuse or sexual abuse. This section should cover the major do­ mains of the patient’s life, including work, love, and recreation. Family history: Presence of psychiatric illness in family members, dementia, psychiatric treatment, use of psychiatric medication, presence or history of substance abuse, and history of suicide or suicide attempts. Past medical history: Past and current medical problems, treatments, and allergies. Medications: Psychiatric, medical, over-the­ counter, and alternative medications.

Mental status exam: General description of the patient’s appearance, speech, mood, affect, thought process, thought content, perceptual disturbance, suicidal ideation, homicidal ideation, sensorium and cognition, impulse control, judg­ ment, insight, and reliability (see Mental Status Exam in the following section). The mental status exam should contain enough information to allow other physicians to recognize the patient from the description alone. Diagnosis: Psychiatry adheres to a biopsychosocial model where problems are understood as consisting of biological, psychologi­ cal, and social dimensions. Diagnosis is made across five separate axes to delineate primary psychiatric disorders and substance abuse, personality disorders and mental retardation, general medical illness, psychosocial stressors, and global functioning. This multiaxial system supports an approach to understanding the pat­ ient, which includes medical, psychiatric, and

social problems. Axis I General psychiatric conditions and substance-related disorders Axis II Personality disorders and mental retar­ dation Axis III General medical conditions Axis IV Psychosocial stressors Axis V Global assessment of functioning (GAF) on a scale from one to 100 (see Table 5)

Differential diagnosis: Include all psychiatric, medical, and neurological possibilities. Assessment/plan: Include the patient’s age, gender, working diagnosis, and reason for admis­ sion or discharge. Write orders to admit the pa­ tient if necessary, specify admission status (eg, voluntary or involuntary), specify observation status (eg, one-to-one, every 20 minutes), con­ sider medical and neurological evaluations, pro­ pose treatment, and recommend gathering addi­ tional information from family and other health care personnel. A/P: Mr. Smith is a 45-year-old man with schizo­ phrenia, paranoid type, who presents with com­ mand auditory hallucinations telling him to jump off the Golden Gate Bridge in the context of medication non-adherence for the past two months.

C Admit to psych 6, voluntary status, q20 observation C Check vital signs q shift, regular diet, NKDA C Restart risperidone at 1 mg bid and titrate as necessary C Contact outpatient psychiatrist to gather additional information (Dr. Jones, x1234)

Table 5. Global Assessment of Functioning
Score 91-100 Description of functioning Superior functioning in a wide range of activities, life’s problems never seem to get out of hand, is sought out by others because of his or her many positive qualities. No symptoms. Absent of minimal symptoms (eg, mild anxiety), good functioning in all areas, interested and in­ volved in a wide range of activities, socially effec­ tive, generally satisfied with life, no more than everyday problems or concerns (eg, an occa­ sional argument with family members). If symptoms are present, they are transient and normal reactions to psychosocial stressors (eg, difficulty concentrating after family argument); no more than slight impairment is social, occupa­ tional, or school functioning (eg, temporarily fall­ ing behind in schoolwork). Some mild symptoms (eg, depressed mood or mild insomnia) OR some difficulty in social, occu­ pational, or school functioning (eg, occasional truancy, or theft within the household), but gener­ ally functioning pretty well, has some meaningful personal relationships. Moderate symptoms (eg, flat affect and circum­ stantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning (eg, few friends, conflicts with peers or coworkers). Serious symptoms (eg, suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning (eg, no friends, unable to keep a job). Some impairment in reality testing or communica­ tion (eg, speech is at times illogical, obscure, or irrelevant) OR major impairment in several areas such as work or school, family relations, judg­ ment, thinking, or mood (eg, depressed person avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). Behavior is considerably influenced by delusions or hallucinations OR serious impairment in com­ munication or judgment (eg, sometimes incoher­ ent, grossly inappropriate behavior, suicidal, pre­ occupation) OR inability to function in almost all areas (eg, stays in bed all day; no job, home, or friends). Some danger of hurting self or others (eg, suicide attempts without clear expectation of death; fre­ quently violent; manic excitement) OR occasion­ ally fails to maintain minimal personal hygiene (eg, smear feces) OR gross impairment in com­ munication (largely incoherent or mute). Persistent danger of severely hurting self or other (eg, recurring violence) OR persistent inability to maintain minimal personal hygiene OR serious suicidal act with clear expectation of death. Inadequate information

81-90

71-80

61-70

51-60

41-50

31-40

21-30

11-20

1-10

0

Adapted from Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, American Psychiat­ ric Association, 2000

The Mental Status Exam
General description: Appearance (clothing, hygiene, posture, body type), behavior (psychomotor agitation, psychomotor retardation, restlessness), and attitude towards the interviewer (cooperative, well-related, guarded, hostile, apa­ thetic). Speech: Quantity of speech (eg, talkative, sparse), rate (eg, rapid, slow), volume (eg, whis­ pered, loud), spontaneous, impediments (eg, stuttering, lisp), and rhythm. Mood: Emotional state recorded in the patient’s own words (eg, “depressed,” “anxious,” “scared,” “happy,” “angry”). Affect: The interviewer’s observation of the pa­ tient’s emotional state, which includes the general quality (eg, dysphoric, euthymic) and depth of the affect (eg, normal, blunted, or flat). Affect may be labile (alternating rapidly between two extremes) or inappropriate (incongruence between subject matter and emotional expression).

paranoid content. obsessions. thought blocking. tactile. and a point is never made Rapid thinking with fast changes in top­ ics. olfactory. but speech may be difficult to follow Flow of thought with ideas that are co­ herent but unrelated Flow of thought is interrupted by si­ lence. or gustatory. and the patient does not return to the same topic when speech re­ sumes Individual ideas and speech are inco­ herent Word association by rhyming Flight of ideas Loosening of associations Thought block­ ing Word Salad Clang associa­ tions Neologisms Creating new words Adapted from Psychiatry Essentials: A Systematic Review. 2001 Perceptual disturbance: Hallucinations may be auditory. or lapse into increasing levels of disorganization. assess abstract vs. Examples of thought con­ tent include suicidal ideation. Table 1. repetitious. word salad.Thought process disturbance: Refers to the logical and semantic connections between pa­ tient’s thoughts (form). Hanley & Belfus Inc. Sensorium and cognition: Administer the mini­ mental state exam (Table 3). tangentiality. Thought Content Disturbance Thought Content Delusions Description Fixed. or neologisms (see Table 1). ideas of reference. Thought Process Disturbance Thought Disturbance Circumstantialit y Tangentiality Description Speech includes irrelevant details but eventually makes a point Speech is not goal-directed. poverty of content. ideas are related. Verbal expression can follow a linear and logical train of thought called goal-directed (normal). such as circumstantial thought processes. or obscure An unfounded fear that triggers panic Ideas of reference Ideas of influence Paranoid ideation Obsession Compulsion Poverty of content Phobia Adapted from Psychiatry Essentials: A Systematic Review. or persecuted A recurrent thought experienced as intrusive A repetitious act designed to allevi­ ate anxiety Thought that is vague. General themes that characterize the patient’s thinking should be described (eg. Table 2. followed. anger at their parents). homicidal ideation. Distinguish between hallucinations and illusions. visual. compulsions. and phobias (see Table 2). loosening of associations. Hanley & Belfus Inc. false beliefs without a cultural basis Belief that the television or radio speaks directly to patient Belief that other forces control the patient’s behavior Thoughts of being harmed. delusions. . 2001 Thought content disturbance: Refers to what the patient is thinking. flight of ideas.

day (1). especially with regard to making medical deci­ sions. fold it in half (1). 79 (1).concrete thinking. 72 (1). . floor (1) “Repeat the names of these 3 objects” table (1). month (1) “Where are you?” state (1). point to a pencil (1) “Say no ifs ands or buts” “Take this paper in your right hand (1). car (1) “Name the object the examiner is holding” point to a watch (1). season (1). country (1). Does the patient see himself as others do? Reliability: Accurate and consistent reporting of symptoms. car (1) Registration 5 3 Attention and Calculation “Subtract by 7s starting from 100” 93 (1). Judgment: Determine the patient’s ability to understand behavior and its consequences. The Mini-Mental State Exam Category Instructions to Patient Maximum Score 5 Orientation “Can you tell me the date?” year (1). date (1). 1975 Impulse control: Assess the patient’s ability to think before acting and their ability to talk about their emotions rather than acting on them. hospital (1). 66 (1) “Recall the names of the above 3 objects” table (1). Insight: Refers to the patient’s awareness and understanding of illness. flower (1). general knowledge. 86 (1). town (1). vocabulary. and overall intelligence. flower (1). truthfulness. Table 3. and put it on the floor (1)” “Read this aloud and do what it says” show the patient a sign that says CLOSE YOUR EYES “Write a sentence of your own” 5 Recall 3 Language 2 1 3 1 1 Construction “Copy this design” show the patient a pair of intersecting pentagons 1 Adapted from Folstein. and extent of disclosure.

Depression . If the patient is suicidal. but con­ gruent with the patient’s reported mood. content disturbance may reach delusional proportions in depression with psychotic features. Ask about irritable or depressed mood. past medications. persistent alcohol use or cocaine withdrawal may present with depressive symptoms. Suicidality: Suicidal ideation is present in more than half of depressed patients. psychomotor agitation or retardation. Thought process: Linear and goal-directed in the majority of patients. Medications: Antihypertensives. anxiolytics. school. loss of interest in previously pleasurable activities. pressured speech.” or “irritable. Past psychiatric history: Previous psychiatric diagnoses. A plan needs to . seasonal variation. posttraumatic stress disorder. but often impoverished. anticonvulsants. analgesics.” “sad. side effects. Parkinson’s dis­ ease. oral contracep­ tives. HIV. decreased libido. duration. and suicidal ideation. sedatives. increased goal-directed activity. diabetes. antibiotics. and substance abuse are the most common comorbid conditions with major depressive disorder. decreased energy. too much or too little sleep. hypnotics. Past medical history: Hypothyroidism. hopelessness. guilt or regret about the past. including dates and locations. anemia. command or visual halluci­ nations may occur with psychotic features. ask about the presence of a plan. Assess severity of depressive symptoms by noting impact on their home. or work life. seizure disorders. antipsychotics. Substance abuse history: Assess temporal relationship between any substance use and depressive symptoms. Perceptual: Auditory. Speech: Decreased volume. changes in appetite. previous depressive or manic epi­ sodes. poverty of con­ tent. problems with concentra­ tion. Mental Status Exam General description: Stooped or downcast posture. and Cushing’s disease may present with symptoms of depression. difficulty staying asleep. or paranoid ideation. distractibility. corticosteroids. Panic disorder. or sometimes restlessness. psychomotor retarda­ tion. slow rate. systemic lupus erythematosus. Assess type of insomnia (sleep onset. diurnal variation in severity of symptoms. Rule out bipolar disorder with questions about periods of persistently elated mood. and chemotherapy may cause depressive symptoms. date of onset. increased self-esteem. speech may not be spontaneous. Thought content: Ruminations of guilt about the past. History of suicide attempts and specific methods employed. poor eye contact. and adherence to treatment. assess potential lethality of previous attempts. stimulants.” Affect: Constricted in dysphoric range. and psychosocial stressors. Mood: Often described as “depressed. history of psychiatric hospitalizations. or hypersomnia). hopeless about the future. Rule out psychotic features or schizoaffective disorder by asking about hallucina­ tions and delusions. migraine headaches. and normal rhythm. weight loss or weight gain. For example. early morning wakening. and hedonism. racing thoughts. outpatient therapy. history of panic attacks or other anxiety symptoms.History Taking History of present illness: Current symptoms.

urinalysis with toxicology screen. chronic disease. substance-induced mood disorder. Judgment: Often impaired by the intensity of depressive symptoms. Homicidality: May occur with psychotic features. dementia. depressed type. Insight: Distorted with exaggerated emphasis on depressive symptoms. infection.” Laboratory data: Complete blood count. vitamin B12 and folate levels. Medical: Hypothyroidism. thyroid function tests. Assess how the patient manages or resists suicidal impulses. or minimize symptoms for fear of appearing “crazy. urine pregnancy test. and adjust­ ment disorder with depressed mood.be specified if present. . Diagnostic testing: The Hamilton Rating Scale for Depression (HAM-D) and the Beck Depression Inventory. cerebral tumors. concentration is often poor. Reliability: Patients may overemphasize symp­ toms in the midst of a depressive episode. liver function tests. Huntington’s disease. temporal lobe epilepsy. Differential Diagnosis Psychiatric: Dysthymia. bereavement. cyclothymia. without disturbance in abstract thinking. schizoaffective disorder. The mini-mental state exam score should be greater than 27 unless depressive pseudodementia is present. bipolar I disorder. some problems with immediate recall (registration). and head trauma. medications. and HIV in high-risk patients. bipolar II disorder. multiple sclerosis. Diagnosis: Axis I: Major depression. The patient may have a good fund of knowledge and vocabulary. and language deficits are rare. Sensorium/cognition: Oriented. Neurological: Parkinson’s disease. blood alcohol level. chemis­ try. and vitamin defi­ ciency. Impulse control: Generally intact except when patients have psychomotor agitation or severe anxiety. but not de­ layed recall. cancer. schizoaffective disorder.

behavioral. Constant visual observation (1:1) should be considered in suicidal patients. such as dysthymia. the history of present illness should describe the full extent of symptoms. The diagnosis of major depression re­ quires at least five of the following nine symptoms for a duration of at least two weeks: depressed mood. and dopamine is the proposed etiological mechanism. and psychodynamic psychotherapy. epinephrine. . B. and adjustment disorder. Genetic factors influence the devel­ opment of depression. II. The examiner should ask about suicidal ideation and the presence of a plan. C. These ele­ ments interact with psychosocial stressors and increase the patient’s vulnerability to affective disturbance. loss of energy. and a dysregulation of serotonin. Fluoxetine is considered a more activating antidepressant and can be used in patients with poor energy and hypersomnia. group. Epidemiology. would be used for patients who experience anxiety and insomnia in their symptom profile. III. Anxiety symptoms and disorders frequently occur with major depression and also in­ crease suicide risk. psychomotor agitation or retarda­ tion. In treating the patient with major depression. interpersonal. family. and in including sea­ sonal pattern or postpartum specifiers. For example. bereavement. appetite changes. feelings of guilt or worthlessness. Patients with clinical depression may require hospitalization for suicidal ideation. C. D.Major Depressive Disorder Discussion I. IV. The time course is important in excluding differential diagno­ ses. Etiology. The specific choice of antidepressant typically depends on symptom patterns and differing side effect profiles.Treatment A. decreased interest in activities. and substance-induced mood disor­ ders should be excluded. most evidence supports the integration of antidepressant medication and psychother­ apy. or if they are unable to care for themselves in their daily lives. References. Psychotherapy options include cognitive. Comorbid substance abuse is also a common finding in depres­ sion. Previous suicide attempts and feelings of hopelessness are associated with an increased risk of suicide. The majority of patients with depression will have suicidal thinking and 10-15 percent will eventually commit suicide. sleep changes. such as paroxetine. B. and suicidal ideation. a more sedating antidepressant. Clinical evaluation A. poor concentration. Major depression affects up to 10 percent of men and 20 percent of women at some point in their lifetime. see page 92. In evaluating the patient with depression.

amantadine. psychotic disorders. disulfiram.History Taking History of present illness: Current symptoms. Note extent of recent stressors. treatments.Mania . and outpatient follow-up. or ideas of refer­ ence. diagnoses. or other special powers. risk-taking behavior. Family history: History of depression. and difficult to interrupt. cocaine. restless. Speech: Rapid rate. hyperactive. but may also be hostile and uncooperative. and grandiosity. excessive involvement in pleasur­ able activities. Thinking is not concrete or abstract. Past depressive symptoms. disrobing in public. such as grandiose delusions. ideas of influence. Homicidality: Typically denies. marijuana. barbiturates. Substance abuse history: Alcohol. Ask about religious preoccupa­ tion and political preoccupation. manic episodes. comorbid alcohol and other substance abuse. increased volume. psychosocial support. levodopa. Assess psychotic features. The patient may be easily distracted. ideas of reference. such as clairvoyance. paranoid delusions. and patho­ logical gambling. Racing thoughts. procarbazine. suicide. inflated self-esteem. duration. Social history: Living situation. They may be engaging and entertaining. Past medical history: Ask about all medical and neurological problems because many diseases can cause symptoms consistent with mania (see differential diagnosis).” Affect: Expansive. methylphenidate) can cause manic symptoms. isoniazid. Ask the patient how much he or she has been sleeping. or command halluci­ nations may occur with psychotic features. marital status. hypersexuality. Assess for concurrent or alternating depressive symptoms. talkativeness. corticosteroids. Thought content: Grandiose delusions of great wealth and intelligence. labile at times with rapid shifts to irritability. Mood: “Great. money spending. especially in mixed­ manic states with depressive symptoms. euphoric. and sub­ stance abuse in family members. includ­ ing impact of manic symptoms on relationships and occupational functioning. Perceptual: Auditory. euphoria. levothyroxine. benzodiazepines. and date of onset. psychotic symp­ toms. and level of education. and analgesics. bromocriptine. distractibility. Sensorium/cognition: Alert and oriented. employment. heroin. Irritability. depending on the patient’s ability to focus or cooperate. hallucinogens. thought broadcasting. feelings of having special powers. suicide attempts. increased quantity. Suicidality: May be present. Thought process: Pressured. sometimes alternating with intense dysphoria. mind reading. ask about energy during the day. Past psychiatric history: Past hospitalizations. with poor atten­ tion and concentration. Medications: Antidepressants. bipolar disorder. Mental Status Exam General appearance: The patient appears ex­ cited. Increased goal-di­ rected activity. with variable immediate and delayed recall. but may be bizarre and incoherent at . elevated mood. and CNS stimulants (eg. with flight of ideas. and psychomotor agitation. and dressed in color­ ful or dramatic clothing. depression during adolescence. visual.

amantadine. ceruloplasmin. cyclothymia. amylase. manic episode. Diagnostic testing: Electroencephalography. procarbazine. corticosteroids. head trauma. Diagnosis: Axis I: Bipolar I disorder. chemis­ try. RPR. renal failure. Insight: Impaired. levodopa. neoplastic disease. Patients experiencing manic episodes may not be able to give accurate infor­ mation about past medical. personal. lipase. antidepressants. levothyroxine. disulfiram. CNS infection. temporal lobe epilepsy. Wilson’s disease. vitamin B3. Judgment: Impaired. vitamin B12. carcinoid syndrome. amphetamines. schizoaffective disorder. Patients may like the symptoms of mania and do not recognize the need for treat­ ment. or substance-abuse histories. liver function tests. thyroid function tests. computed tomography. borderline personality disorder. Neurological: Huntington’s disease. bipolar type. . Laboratory data: Complete blood count. The patient may be hypersexual and repeatedly attempt to touch the examiner. Reliability: Limited.times. vitamin B12 deficiency. substance-in­ duced manic symptoms (eg. and medication-induced mania (eg. cerebrovascular accidents. bromo­ criptine. PCP). magnetic resonance imaging. Impulse control: Impaired. CNS stimulants). and toxicology screen. schizoaffective disorder. psychiatric. Medical: Hyperthyroidism. multiple sclerosis. and Pick’s disease. Manic patients often do not understand how their symptoms affect behavior or other people. Differential Diagnosis Psychiatric: Bipolar II Disorder. vitamin B3 deficiency (pellagra). isoniazid. and delirium.

a patient may cycle frequently between dis­ crete episodes of mania and major depres­ sion (ie. Epidemiology. Manic patients can be violent. II. There is no such entity as unipolar mania. Hypomania may eventually progress into mania. D. Symptoms of psychosis are often elicited by first asking. decreased need for sleep. and degree of functional impairment. B. B. duration. C. are started for long-term prophylaxis of mood cycling.Throughout the course of bipolar disorder. racing thoughts. and family psychotherapy also play important roles in helping patients and families develop insight and cope with chronic illness. References. It is equally prevalent in men and women. Bipolar I disorder affects approxi­ mately one percent of the population. One proposed etiology is impaired regulation of the biogenic amines. and this is an important distinction between mania and hypomania. “Have you felt like your mind has been playing tricks on you?” Ask about unusual or odd experiences. Clinical evaluation A. Mania is characterized by elevated mood and at least three of the following seven symptoms for a period of one week: inflated self-esteem. Patients who present with manic symptoms may require inpatient hospitalization be­ cause they are a danger to themselves or others due to impulsive behavior and im­ paired judgment. date of onset. Hypomania is a less severe form of mania that does not occur with psychotic features and is consistent with a separate diagnostic entity called bipolar II disorder. pressured speech. Four symp­ toms are required for diagnosis if the mood is only irritable. E. and hedonism. in­ creased distractibility. Psychotic features may occur in the context of a manic episode. III. particularly serotonin and norepinephrine. Bipolar disorder is associated with genetic factors. see page 92. Mania occurs in the context of bipolar I disorder and schizoaffective disorder. C. recent stressors. Psychosis . and carbamazepine. such as lithium.Treatment A. supportive therapy. rapid cycling).Acutely manic patients may be unreliable historians. even in the absence of past depressive symptoms.The presence or history of one manic epi­ sode is sufficient to make the diagnosis of bipolar disorder. but the pattern of inheritance remains unclear. IV.Bipolar I Disorder Discussion I. or in some instances. . mixed state). Etiology. There is often a delay in the diagnosis of bipolar disorder because the disorder may initially present with depressive symptoms. and symptoms typically begin late in adolescence. increased goal-di­ rected activity. bipolar type. and manic symptoms may not develop for many years. experience these episodes concurrently (ie. especially on inpatient units. sodium divalproex.History Taking History of present illness: Current symptoms.Acute mania is treated with antipsychotic medication and benzodiazepines because these agents have sedative effects. Mood stabilizers. and the diagnosis of mania is often made based on information from friends and family in combination with the patient’s mental status exam.Psychoeducation.

social and sexual activity. (including command hallucinations. head trauma. Wernicke-Korsakoff syndrome. job history. tactile. seizures. can also cause psychotic symptoms. relationship history. ideas of reference. and olfactory hallucinations. medication history with duration and dosages. and side effects from past medications: dystonia. neurosyphilis. and whether hospitalizations tend to occur during a specific time of year. anticholinergics. and Wilson’s disease. Past medical history: Psychotic symptoms can be caused by delirium. Ask about symptoms of clinical depression and mania to exclude schizoaffective disorder. Ask the patient to describe where the voices are coming from (eg. and agitated behavior. Substance abuse history: Rule out substance­ induced psychotic symptoms with questions about alcohol. Family history: Presence of psychotic disorders or odd and eccentric personality traits in family members. paranoid thinking. Ask the patient about negative symptoms such as anhedonia. distant relatives. systemic lupus erythematosus. duration of hospitalization. parkinsonism. or neolo­ gisms. childhood trauma or illness. and management by an intensive case manager or outpatient therapist. Assess delusional con­ tent. number of voices the patient hears. AIDS. apathy. and social withdrawal. and levodopa can all cause psychotic symptoms. adherence. Assess number of hospitalizations. Suicidal ideation. social functioning. and source of income. and voices commenting or conversing). amphetamines. special powers. Social history: Prenatal insults. CNS lesions. symptoms of previous psychotic episodes. ideas of influence. and PCP use. cannabis. num­ ber per year. and reasons for first hospitalization. tardive dyskinesia. loosening of associations. . Assess the impact of psychotic symptoms on daily functioning. treatment adherence. word salad. Ask about the presence of visual. recre­ ational activities. day treatment programs. hallucinogens. thought insertion. delusions of guilt or sin. major depression with psychotic features. Assess disorganized behavior by asking about eating habits. thought broadcasting.auditory. level of education. Parkinson’s disease. suspiciousness. Corticosteroids. Medications: Ask about medical and psychiatric medications. Withdrawal from sub­ stances. and who administers the medication. somatic delusions. and a history of suicide attempts should also be assessed. fear. or bipolar I disorder. such as circumstantiality. inside or outside their head). hallucinations. Past psychiatric history: Previous psychiatric diagnoses. herpes encephalitis. housing. dosages. akathisia. Ask about a history of violence or responding to command hallucinations. Previous treatments. and magical thinking. or other household members. cocaine. such as barbiturates and alcohol. dementias. derailment. grandiose delusions. Allow the patient to speak freely to assess the presence of thought disorders. date of first psychiatric contact. plans. tangentiality. cerebrovascular disease. and neuroleptic malignant syndrome. Ask about current psychiatric care.

tactile. Thinking is usually concrete. Thought process: Illogical. dementia. poorly related. shared psy­ chotic. delirium. Impulse control: Possibly poor impulse control (eg. visual. RPR. B12 deficiency. Scale for the Assessment of Negative Symptoms (SANS).Mental Status Exam General description: Disheveled. uncooperative at times. schizophreniform. olfactory. WernickeKorsakoff syndrome. borderline. or gustatory. Judgment: Impaired. and somatic. possible psychomotor agitation or retardation (including catatonia). Mood: “Fine. poverty of speech (alogia). Laboratory data: Complete blood count. and malin­ gering. Creutzfeldt-Jakob disease. Suicidality: Suicide attempts occur more fre­ quently in patients with psychotic disorders. doctors. government agencies or strangers. cerebrovascular disease. obsessive-compulsive disorder (OCD). and Wilson’s disease. although auditory hallucinations are most common. and paranoid personality disorders. schizoid.” or “scared. Sensorium/cognition: Alert and oriented. Medical: AIDS. friends. substance-induced psychotic disorder. Poor concentration. systemic lupus erythematosus. Insight: Limited. erotic. vitamin B12 and folate levels. neurosyphilis. computed tomography. Speech: Normal rate. schizotypal. thyroid function tests. chemis­ try. possi­ ble impairment in the ability to immediately repeat or recall words depending on the presence of distracting hallucinations or formal thought disor­ der. menac­ ing.” “bad. rhythm. The patient does not understand why he has been brought to the hospital. Neurological: Epilepsy.” Affect: Often blunted or flat. urinalysis with toxi­ cology screen. or grandiose delusions. Reliability: May be significantly impaired. . Ideas of reference. herpes encephalitis. and delusional disorders. Thought content: Paranoid delusions about family. and volume. cerebral neoplasm. and the Scale for the Assessment of Positive Symp­ toms (SAPS). the patient may appear to be responding to hallucinations. Corrob­ orative data is usually helpful. and normal pressure hydrocephalus. Diagnosis: Axis I: Schizophrenia. brief psychotic. carbon monoxide or heavy metal poisoning. The patient has a markedly altered sense of reality. guarded. bipolar I disorder. HIV testing. lunges at security guard about whom patient has become paranoid). with loosening of associations. tangential. and 10 percent of people with schizophrenia will eventually commit suicide. and serum ceruloplasmin. schizoaffective. suspicious. head trauma. coworkers. Homicidality: Homicidal ideation directed towards objects of paranoia. fair fund of knowledge and vocabulary. Perceptual: Hallucinations may be auditory. neighbors. blood alcohol level. autistic disorder. Diagnostic testing: Electroencephalography. factitious disorder. Differential Diagnosis for Psychosis: Psychiatric: Major depression with psychotic features. liver function tests. The mini-mental state exam is not reliable in acutely psychotic patients. thought insertion or withdrawal. or magnetic resonance imaging for new onset psychosis. no apparent language deficits.

and compulsions.The history of present illness should focus on specific symptoms. Two out of five symptoms for a duration of at least 6 months are required for diagnosis. schizophreniform disorder. paraesthesias. Socio­ occupational functioning in Delusional Disor­ der may not be impaired beyond the direct effect of the delusion itself.Schizophrenia requires lifelong treatment with antipsychotic medication. severe distress from their psychosis. agitated behavior that is potentially dangerous. elevators). nausea. C. needles. III. Schizoaffective disorder is diagnosed in the presence of psychotic symptoms and a prominent mood disturbance. hallucinations. C. fears. References. Delusional disorder occurs in older patients and is char­ acterized by non-bizarre delusions. such as fears of . Shared psychotic disorder is rare and occurs in the context of a close relationship with another person who suffers from a known psychotic illness. The stress diathesis theory is the prevailing model.The difference between schizophrenia. disorganized speech.Day treatment programs.History Taking History of present illness: Current symptoms. chest pain. obsessions. There are no pathognomonic signs of schizo­ phrenia. The typical age of onset for schizophrenia is in young adulthood. irritability. dizziness. or if they are unable to care for themselves. or social isolation during childhood. performance. D. disorganized behavior. affecting one percent of the population. such as risperidone or olanzapine. II. and brief psy­ chotic disorder is mainly in symptom dura­ tion. and premorbid functioning. but men are initially affected earlier than women. Treatment A. heights. are currently the first line of treatment. D. illness duration. and it posits that schizo­ phrenia results from an interaction between biologic vulnerability and environmental stress. Atypical antipsychotics. Anxiety . B. duration. frequency.The five main symptoms of schizophrenia are delusions.Discussion I. derealization or depersonalization phenomena. Schizophrenia is the most common psychotic disorder. Ask about panic symptoms. phobias (eg. time of onset. and negative symptoms (ie. Ask about agoraphobia and other avoidant behav­ ior. A genetic basis for schizophrenia is widely accepted. see page 92. feeling of choking.Patients with schizophrenia may require admission for suicidality. animals. play a supportive role in the treatment of psychotic disorders.Schizophrenia . deficits in personal and social function). withdrawn behavior. Men and women are equally affected. Screen specifi­ cally for obsessive-compulsive disorder (OCD) with questions about obsessions. symptom triggers. somatic complaints. Epidemiology. including psychosocial therapies. B. and fear of losing control or dying.Psychotic symptoms may also occur in clini­ cal depression and mania. Assessment of premorbid personality characteristics may reveal shy.Clozapine is reserved for treatment-resistant schizophrenia. such as palpitations. prodromal signs. trembling. Etiology. IV. worries. sweating. and the symptom presentations vary widely. shortness of breath. Clinical evaluation A.

Understands the nature and consequences of his illness. and cerebrovascular disease can all mimic or directly cause symptoms of anxiety. opioids and benzodiazepines can also cause anxiety. but congruent with stated mood. opioid. avoidant behavior. and adherence. exposure to violence. Sensorium/cognition: Alert and oriented. or visual hallucinations. hand washing. intru­ sive recollections of the event. nicotine. may be more talkative than usual. pharmacologic treat­ ments.” “out of control. Thought content: Preoccupied about somatic complaints. or war. For posttraumatic and acute stress disorder. Screen for comorbid alcohol. sexual abuse. asthma. and hallucinogens may pro­ duce symptoms of anxiety. and hyperarousal with insomnia. Mental Status Exam General description: Restless. Insight: Good. penicillin. hypoglycemia. disasters. and theophylline may cause anxiety. The mini-mental state exam score is greater than 24. hypertension. Past psychiatric history: Previous psychiatric diagnoses. COPD. Abruptly stopping antidepressant and anxiolytic medication may also cause anxiety. Thought process: Pressured. fidgeting. Huntington’s disease and a history of head trauma increase the risk of OCD. ruminative. side effects. and startling easily. phobia or obsessions. psychomotor agitation. decreased interest in activities. Speech: Rate may be increased. antihyperten­ sives. . antichol­ inergics. such as clean­ ing. which appears similar to anxiety. Withdrawal from alcohol. Assess history of psychiatric hospi­ talizations. Social history: Details of trauma history. nightmares. ordering. physical abuse. psychotherapy. Antipsychotic medications may induce a state of restlessness known as akathisia.” Affect: Anxious. Impulse control: Fair. Substance abuse history: Amphetamines. Suicidality: May be present. Judgment: Fair.” “nervous.contamination. epilepsy. poor concentration. untreated anxiety is a risk factor for suicide. patient is afraid of what bad events may happen in the future. cannabis. no apparent lan­ guage deficits or disturbance in abstract thinking. but with normal rhythm and volume. carcinoid syndrome. although the patient may place exaggerated emphasis on anxiety symptoms. Assess comorbid depressive symptoms. command auditory. myocardial infarction. Past medical history: Mitral valve prolapse. history of Tourette’s disorder. Medications: Aspirin. and compulsive slowness. Mood: “Scared. panic attacks or phobias in the past. and need for symmetry. No evidence that the patient is a danger to himself or others. or separation anxi­ ety as a child. Perceptual: No auditory. and prescription medication abuse and dependence. intact memory. Ask questions about accompanying compulsions. especially with comorbid clinical depression. caffeine. Homicidality: Rare. irritable. checking. pathological doubt. ask about exposure to a life-threatening event. hypervigilance. hyperthyroidism. sympathomimetics. but linear and goal-directed. fearful of recurrent panic. intrusive thoughts. counting. good fund of knowledge and vocabulary.

fear of dying. dysthymia. asthma. cerebrovascular disease. Anxiety Disorders . chronic obstructive pulmonary disease. but a combination of in­ creased sympathetic discharge. fear of losing control. nausea. calcium. Clinical evaluation A. Neurological: Epilepsy. cardiac arrhythmias. urine pregnancy test. chills or hot flushes. Generalized anxiety disorder is character­ ized by at least six months of pervasive worry or concern in addition to symptoms of muscle tension. III. and head trauma. carcinoid syndrome. restlessness. insomnia. vitamin B12 and folate levels. thyroid function tests. anticipatory anxiety about having attacks. Differential Diagnosis Psychiatric: Adjustment disorder with anxiety. In order to diagnose panic disorder. need for symmetry and slowness. substance intoxication or withdrawal. feelings of chok­ ing. social phobia. and difficulty concentrating. and hypoglycemia. hyperthyroidism. chemis­ try. obsessive-compul­ sive disorder. agoraphobia. hypochondriasis. echocardiography. Medical: Myocardial infarction. hyperten­ sion. and subsequent avoidant behavior. Generalized Anxiety Disorder. Panic attacks last between five and 20 minutes and are characterized by at least four of the following 13 symptoms: palpita­ tions. dizziness. Symptoms of OCD follow several patterns. Panic disorder may occur with or without agora­ phobia. paraesthesias. urinalysis with toxicology screen and blood alcohol level. Etiology. trembling. angina. irritability. posttraumatic and acute stress disorder. specific phobia. Diagnostic testing: Electrocardiography. obsessive-compulsive. separation anxiety disorder. vertigo. such as obsessive fears of contamination and compulsive cleaning.Reliability: Good. chest pain. Diagnosis: Axis I: Panic disorder. liver function tests. impaired regulation of serotonin. de­ pendent. B. The etiology varies according to the specific disorder.Discussion I. C. somatization disorder. factitious disorder. shortness of breath. and specific triggers for anxiety can often be clearly identified by the patient. tumors. . mitral valve prolapse. major depression. and chest x-ray. the patient must experience panic attacks. Anxiety disorders are among the most common psychiatric diagno­ ses and typically begin in adolescence or young adulthood. II. Laboratory data: Complete blood count. and classical condition­ ing (ie. Symptoms are described consistently. hyperparathyroidism. sweating. and borderline personality disorders. specific stimuli become paired with anxiety responses) account for most symptom presentations. Obsessive-compulsive disorder is character­ ized by recurrent and intrusive thoughts that cause anxiety (obsessions) and repetitive behaviors designed to relieve the anxiety (compulsions). and pathological doubt and checking. avoidant. Epidemiology. Anxiety may be an appropriate and adaptive response to stress but is consid­ ered pathological when symptoms begin to impair functioning. and derealization or depersonaliza­ tion.

relaxation techniques. and self-injurious behavior. war. and feeling of a foreshortened future. stress disor­ ders. and rigid coping mechanisms. and dependence over time. Substance abuse history: Alcohol and drug abuse are very common comorbid conditions in posttraumatic stress disorder. mirtazapine. Behavioral therapy with techniques such as graded exposure. Ask about associated symptoms such as survivor guilt. Assess symptoms of increased arousal. Social history: History of exposure to trauma. such as clinical depression.History Taking History of present illness: Ask about a traumatic event witnessed or experienced directly. Evaluate current social support and recent stressful life changes. and exaggerated startle response. burglary. or unless there are other potentially dangerous comorbid psychiatric problems. specific phobia. agoraphobia). rape. and hypnosis is used in OCD. hallucinations. anger. irritability. Acute Stress and Posttraumatic Stress . Clomipramine. C. recurrent recollections. decreased interest in activities. anxiety. Assess symptoms of re-experiencing the event through nightmares. Pharmacotherapy consists of selective­ serotonin reuptake inhibitors. terrorism. Acute stress and posttraumatic stress disor­ ders are also categorized as anxiety disor­ ders and are reviewed in the following chap­ ter. Avoidant behavior of stimuli associated with the trauma. Assess premorbid risk factors. Hospitalization is rarely required unless anxiety precludes patients from taking care of themselves (eg. impulsivity. Specific phobias are focused on stimuli.Treatment A. but may lead to symptom exacerbation. hyperactivity. physical abuse. IV. Cognitive-behavioral therapy is effective in panic disorder. such as borderline personality traits. panic attacks. and illusions. decreased concentration. panic disorder. shame. and sexual abuse. feeling that external events (rather than internal) control life changes. Past psychiatric history: Major depression. systematic desensitiza­ tion. E. social phobia. venlafaxine. B. Symptoms of substance intoxication or withdrawal may mimic posttraumatic stress symptoms. and buspirone are also effective. tolerance. agoraphobia. References. disasters. and personality disorders occur with increased frequency in patients who experience posttraumatic stress disorders. Social phobia involves fears of humiliation and embarrass­ ment in public. emotional numbing. Psychosocial therapies play a significant role in the treatment of anxiety disorders. . hostility. such as animals or needles. Benzodiazepines are a very effective short­ term treatment. substance abuse.D. flashbacks. history of childhood trauma. and GAD. suicidal ideation. such as. nefazodone. somatic symptoms. obsessive-compul­ sive disorder. date of event. depression. and duration of current symptoms. sleep abnormalities. see page 92. decreased libido. detachment from other people. guilt about not preventing the traumatic experience. and agoraphobia.

II. and recurrent thoughts about traumatic event. and blood alcohol level. or dysphoric. acute stress disorder. the mini-mental state exam score re­ mains greater than 24. The patient may storm out of the interview when an unpleas­ ant question is posed. Differential diagnosis: Head trauma. illusions. Suicidality: Passive ideation to end suffering. Thought content: Ruminations of guilt. and attention could be impaired. Insight: Good.” “nervous. less commonly. rejection. Clinical features of PTSD follow three . Sensorium/cognition: Alert and oriented. panic disorder. history of head trauma. The patient is able to stop him­ self from hurting other people. and chronic medical illness. concentration. Clinical evaluation A. substance-related disorders. adjustment disorder. Mental Status Exam General appearance: Restless. borderline personality disorder. Reliability: Fair. Patients with borderline personality traits or a past history of childhood trauma are more likely to experience symptoms following a traumatic event.Family history: Psychiatric illness or history of trauma in first-degree family members. Laboratory data: Complete blood count. or alternative treatments. biological and psychosocial factors also contribute because only a minority of people who experience trauma develop PTSD. seizure disorder. rapist). anxious. Medications: All psychiatric. urine toxicology screen. but memory. The patient may overemphasize the extent of the symptoms. factitious disorder. an active plan.” “depressed. Epidemiology. urine pregnancy test. generalized anxiety disorder. The patient understands the nature of symptoms and underlying illness. seizure disorder. medical. or withdrawn with poor eye-contact secondary to feelings of humiliation. rhythm is typically normal. Posttraumatic Stress DisorderDiscussion I. “on edge. chemis­ try. and malingering. However. But patient may have non­ specific homicidal ideation towards those per­ ceived to be responsible for the trauma (eg. and. Etiology. phobias. major depression. over-the­ counter. Diagnosis: Axis I: Posttraumatic stress disorder and acute stress disorder. PTSD is caused by the traumatic stressor. III. Posttraumatic stress disorder (PTSD) occurs following a traumatic event involving the risk of death or physical injury that is either witnessed or experienced directly. Impulse control: Possibly impaired. post-con­ cussion syndrome. PTSD may occur in up to 30 percent of people who experience trauma and is common in combat veterans and victims of assault. rape. dissociative disor­ ders. Thought process: Linear and goal-directed. Homicidality: Denies. and flashbacks. Speech: Rate and volume may be increased or decreased. Past medical history: Childhood illness. Judgment: Fair.” Affect: Irritable. dysthymia. Mood: “Scared.” hypervigilant. or terrorism. Perceptual: Olfactory or other hallucinations reminiscent of event.

References. and attention.History Taking History of present illness: Begin with questions about current symptoms and duration. III.major symptom patterns: re-experiencing the event. but imipramine and amitriptyline have also been used. assess gradual or stepwise decline. Long-term. hypervigilance. and remote memory. psychotic symptoms in the past. Dissociative symptoms may also occur. Ask questions about memory loss. B. irritability. apathy. exaggerated startle response. memory for time. continuous alcohol abuse can cause dementia. Clonidine may be an effective adjunctive treatment to reduce sympathetic arousal. place. recent memory. Substance abuse history: Alcohol intoxication and withdrawal may cause cognitive impairment. motor activity (apraxia). and cognitive therapy. and impaired concentra­ tion. delusional thinking. C. impulsivity. planning. supportive therapy. person. Treatment A. Ask about previous amnestic episodes. If cognitive impairment is worsening. Past psychiatric history: Clarify a history of depressive symptoms to consider pseudodementia. Acute stress disorder is diagnosed when symptoms begin within four weeks of the event and last less than four weeks. and increased arousal. recognizing faces. Rule out delirium by assessing causative precipitants. Long-term management is usually achieved with selective-serotonin reuptake inhibitors. domestic chores). level of conscious­ ness. amnesia. activities of daily living (eg. naming objects. and a history of transient cognitive impairments associ­ ated with medical illness or surgery. avoiding stimuli associ­ ated wi th the traumatic event. Pharmacotherapy includes the use of sedatives and hypnotics for the acute symp­ toms of anxiety and sleep disturbance. insomnia. and executive functioning should be assessed in addition to memory loss (amne­ sia). Ask about diurnal variation of symptoms (sundowning). dressing. and cyproheptadine may specifically reduce nightmares. and perceptual disturbance. avoidant behavior. Language distur­ bance (aphasia). and psychotic symptoms. Patients with PTSD may require inpatient hospitalization for stabilization in cases of suicidal risk or if functioning has become severely impaired. Patients may experience amnesia or feel as though they have stepped outside of their bodies and exist in a state of unreality. depressed mood. Ask about word finding difficulties. tricyclic antidepressants. Nightmares and flashbacks are common symptoms that are typically accom­ panied by anxiety. The onset of PTSD symptoms may occur at any time following the traumatic event. Determine acute or gradual onset of symptoms. . Cognitive Impairment . anger. wandering. organizing. recogni­ tion (agnosia). tying shoes. Clonidine. C. A focus on facilitating improved coping mechanisms and behavior therapy with relaxation training may also be helpful. agitation. B. symptom acuity. and concentrating. Psychosocial treatment involves encour­ aging the patient to discuss the details revolving around the event. see page 92.

Registration and recall may be impaired. Mood: “Fine. RPR. steroids. Ask about risk factors associated with m u l t i -i nfa r c t d e m e n t i a : h yp e r t e n s i o n . anticonvulsants. Social history: Ask about housing.Ask about extent of use. supervised living. demented patients should be alert. Insight: Insight is characteristically absent. nursing home care. children. and blackouts (anterograde amnesia). but may not be oriented to place or time. . and dietary supplements. but possibly dysarthric if associated with cerebrovascular disease. homocysteine level. Patients have aggres­ sive outbursts with difficulty controlling anger. Speech: Normal rate. difficulty following train of thought. and hypercoagulable states. and confabulation. atrial fibrillation. obesity. Reliability: Impaired. Suicidality: Varies with level of self-awareness and presence of psychosis or affective symptoms. Laboratory data: Complete blood count. and labile with inter­ mittent hostility. concentration is impaired. Mental Status Exam General appearance: Disheveled. Ask about over-the-counter medications. seizures. tangential. Judgment: Impaired. toxicology screen. Perceptual: Auditory. patients may bunch numbers together. or indicate the time incorrectly. demyelinating disorders. Medications that can cause symptoms of dementia include anticholinergics.” Affect: Dysphoric. Toxic levels of medications can cause delirium (eg. and the assistance of a home-health aide. thiamine level. shakes.” “depressed. CNS infection. and anticonvulsants. vitamin B12 and folate levels. liver disease (hepatic encephalopathy). withdrawal symptoms. thyroid function tests. hypnotics). disinhibition. Medications: Obtain details of medications with dosages and duration of treatment. marital status. The mini­ mental state score will be less than 24 in de­ mented patients. Huntington’s disease. head trauma. anticholinergics. smoking. visual. and Parkinson’s disease have a pattern of familial inheritance and may be associated with symptoms of dementia. Sensorium/cognition: Non-delirious. perseverative at times. Impulse control: Limited. sedatives. and patients tend to minimize symptoms. systemic lupus erythematosus. and HIV testing. Family history: Alzheimer’s disease. urinalysis. poorly related. word finding difficulties are common. Thought content: Paranoid delusions. diabetes. and confused. irritable. and volume in general. skip num­ bers. Benzodiazepines can mimic or exacerbate symptoms of dementia by causing confusion. Homicidality: May occur in association with paranoia. angry and uncooperative. income. and amnesia. Past medical history: Assess history of cerebrovascular disease. inattentive. hyperlipidemia. cardiovascular disease. alternative treat­ ments. antihypertensives. and apraxia affects ability to follow commands. chemis­ try. and safety in the home. such as people stealing from the patient or impersonating family members. Thought process: Illogical. and renal disease (uremia). delirium tremens. Family members and care­ givers should be interviewed for information. On the clock-drawing task. and command hallucinations are possible. antipsychotics. antihypertensives. Assess extent of family sup­ port. rhythm. Patients are socially inap­ propriate and potentially disinhibited. limited eye contact.

Boston Naming Test (language). hepatic encephalopathy. demyelinating disorders. progressive decline in cognitive functioning. dementia. hydrocephalus. amnesia. uremia. the primary task is to rule out delirium and reversible causes of dementia. Approximately 40 percent of all patients have a family history of the disease. C. However. computed tomography. depression. Medical: Alzheimer’s disease. and normal aging. Differential Diagnosis: Psychiatric: Amnesia. Alzheimer’s disease is a result of neuropathological changes that include amyloid protein deposition. or apathetic behavior. Hachinski ischemia score. Language disturbance can cause word-finding difficulties (aphasia). Wilson’s disease. Diagnosis: Axis I: Delirium. Alzheimer’s disease is more likely than with other causes of dementia to cause personal­ ity changes and aggressive.Diagnostic testing: Chest x-ray. Wisconsin Card Sorting Test (executive function). Trail Making A and B (cogni­ tive processing speed). and planning and organizational abilities are often impaired (executive functioning). Parkinson’s disease. Hunting­ ton’s disease. Alzheimer’s disease is respon­ sible for approximately half of all cases of cognitive impairment in the elderly. Halstead Battery Category Test (abstraction). Parkinson’s disease. vitamin B12 and folate deficiency. and Huntington’s disease. mania. dementias. Vascular dementia shows a more stepwise decline in functioning where each infarct causes abrupt impairment. The hallmark of dementia is memory loss (amnesia). They may fail to recognize objects or family members (agnosia). Vascular dementia causes 15 to 20 percent cases of cognitive impairment in the elderly. hypercalcemia. Epidemiology. Demen­ tia affects up to 50 percent of the population over age 85. traumatic brain injuries. Alzheimer’s and vascular dementia together account for the vast majority of dementia cases. Delirium is associated with medical illness and surgical procedures. HIV-related dementia. B. III. Lewy Body dis­ ease. II. The onset and progression of cognitive decline provide important clues to the diagnosis. B. In evaluating a patient with cognitive impair­ ment. Patients with un­ derlying dementia and the elderly are at the greatest risk of developing delirium. Etiology A. magnetic resonance imaging. such as Lewy Body disease. cerebral neoplasm. D. Vascular dementia is caused by multiple infarctions due to atherosclerotic plaques and thromboemboli occluding cerebral vessels. Patients may wander in their neighborhood. such as dressing or tying shoelaces (apraxia). Weschler memory scale. Pick’s disease. hyperthyroidism. C. and Delirium Rating Scale. vascular demen­ tia.Discussion I. schizo­ phrenia.Clinical evaluation A. pace around their house. Dementia . heavy metal poisoning. depres­ sion (pseudodementia). digit span test (attention and recall). Patients with Alzheimer’s dementia typically demonstrate a gradual. Pick’s disease. irritable. Delirium causes . and have difficulties with everyday tasks. should be considered in the differential diagnosis. CNS infection. Weschler Adult Intelligence Scale. sarcas­ tic.

extent of family support. and obesity. and psychotic symptoms. and hyperthermia. marital status. diabetes. arousability. although the symptom presentation is similar to dementia. Family history: Ask about family history of psy­ chiatric illness and dementia. and impaired cognitive functioning. reversal of the sleep-wake cycle. agitation). sundowning). Assess psychomotor distur­ bance. Past psychiatric history: Ask about previous delirious episodes. changes in the flow of speech. Delirium . Ask about abnormalities of mood (eg. and dura­ tion. Hypoactivity may manifest with slowed reaction time. such as hypertension. ability to sustain attention. Vascular dementia is treated by reducing risk factors. and agitated be­ havior associated with dementia. see page 92. Atypical antipsychotics are used to treat delusions. nau­ sea. vomiting. E. extent of use. and language distur­ bance. Agitated behavior is the most common reason for admission for patients with de­ mentia or delirium. disorientation. such as. B. IV. Ask about current symptoms. memory impairment. Ask about sleep disturbance. catatonia. Alzheimer’s disease is treated with cholinesterase inhibitors for symptomatic improvement and to possibly slow cognitive decline. Substance abuse history: Alcohol intoxication and withdrawal may cause cognitive impairment. Delirium does not occur more frequently among family members unless the underlying etiology is heritable. such as hyperactivity with increased startle response. and exacerbation of symptoms at night (ie. Ask about all substances used. fluctuating levels of conscious­ ness. anger). flushing. hallucinations. . and behav­ ior (eg. C. amnesia. Alcohol depend­ ence increases the risk of developing delirium. Language disturbance may include rambling. and chil­ dren. hypnopompic and hypnagogic halluci­ nations. psychotic symptoms in the past. daytime drowsiness. employment. nature of onset. smoking. and reduced clarity of awareness of the environment. delirium. perception (eg. visual hallucinations). causative precipitants. Social history: Ask about housing. and history of withdrawal symptoms.a sudden onset of mental status changes with altered level of consciousness and a rapidly fluctuating course. nightmares. hyperlipidemia. insomnia. and depression. Delirium requires treatment of the underlying etiology. References. tachycardia. and a history of transient cognitive impair­ ments associated with medical illness or surgery.History Taking History of present illness: Assess impaired consciousness. Treatment A. D. Assess cognitive changes. Supportive psychotherapy may help pa­ tients and their families to cope with the stress associated with loss of autonomy. ability to focus. sweating. declining health. delirium develops over a short period of time and symptoms fluctuate over the course of the day. or incoherent speech.

hypoxia. folate). substance withdrawal delirium. limited eye contact. steroids). B12. medi­ cation toxicity (eg.Past medical history: Assess history of seizure disorder. Thought process: Tangential. and Delirium Rating Scale. head trauma. uremic encephalopathy. confused. Laboratory data: Complete blood count. heavy metal poison­ i n g . Mood: “Angry. Insight: Fair. substance intoxication delirium. and folate levels. lithium. serum medication levels. with dosages and duration of treatment. antipsychotics. Perceptual: Auditory and visual hallucinations are most common in delirium. vascular disease. Toxic levels of anticholinergics. and dissociative disor­ ders.” “afraid. Attention and thinking are typically too impaired to give a reliable history. Sensorium/cognition: Not alert. and electrolyte imbalance. Impaired memory and concentration. computed tomography. Table 6. liver disease (hepatic encephalopathy). HIV testing. steroids. Patients realize the nature of their symptoms. thiamine. vita­ min B12. h e p a t i c encephalopathy. Medical: Epilepsy. Diagnostic testing: Electroencephalography. Dementia Delirium Clouding of conscious­ ness Dementia No changes in conscious­ ness . Patients may be ag­ gressive with difficulty controlling anger. Suicidality: Varies according to the presence of psychosis and affective symptoms. rhythm. and renal disease (uremia).” Affect: Dysphoric. neoplasm. and labile. antihypertensives. and lumbar puncture with CSF examination if indicated. Reliability: Limited. Judgment: Impaired. urinalysis. thyroid function tests. blood and urine cultures if indicated. RPR. chest x-ray. thiamine. Ask about over-the-counter medication and alternative treatments. anticonvulsants. incoherent. mania. infection. toxicology screen. infection. irritable. Ask about cardiovascular disease. depression. poor attention and limited problem-solving abilities. Speech: Normal rate. and sedatives can cause delir­ ium. Medications: Obtain details of medications. chemis­ try. antipsychotics. cardiac failure. with fluctuating level of consciousness. Homicidality: May occur in association with paranoia. Delirium vs. or irrelevant speech. or trauma. schizophrenia. brief psychotic disorder. anticholinergics. substance intoxication or withdrawal. Patients may be inappropri­ ate and disinhibited. and volume. Impulse control: Limited. and delirium not otherwise specified Differential Diagnosis Psychiatric: Dementia. disoriented. lithium. delirium due to multiple etiologies. antihypertensives. anticonvulsants. Diagnosis: Axis I: Delirium due to a general medical condition. sedatives. Mental Status Exam General appearance: Inattentive. e n d o c r i n e d ys f u n c t i o n . Thought content: Paranoid delusions without systematized content. vitamin deficiencies (eg. carbon dioxide toxicity.

and the reticular formation may be the primary neuroanatomical area. and malnutrition. or other accidents. Treatment A. The hallmark of delirium is clouding of consciousness accompanied by a reduced ability to sustain attention. pallor. II. D. The most common causes of delirium are central nervous system disease. Patients typically have impaired cognitive function with mem­ ory deficit and disorientation. Suicidal Ideation . Acetylcholine has been hypothesized to be the major neurotransmitter involved in delir­ ium. Causes of postoperative delirium include pain. The presence of delirium increases mortal­ ity. Symptom severity may fluctuate over the course of the day. or intensive care units expe­ rience delirium over the course of their hospital admission. B. electrolyte imbalance. Agitated behavior is the most common reason for admission or consultation in patients with delirium. IV. physostigmine may be used in repeated doses. tremor. Epidemiology A. In anticholinergic toxicity. nau­ sea. Patients must be carefully monitored to avoid potential harm from falls. Neurological signs of delirium may include dysphasia. ataxia. References. sweating.History Taking .Clinical evaluation A. B. C. Symptoms tend to develop abruptly over several hours and may last days to weeks. C. ranging from severe impairment and disorganization to periods of lucidity. alcohol dependence. Etiology A. III. Maintaining an environment that minimizes stimulation may reduce agitation. Patients with underlying dementia and the elderly are at the greatest risk of developing delirium.Discussion I. agitated behavior. systemic disease (eg. tachycardia. and vomiting. B. and blood loss. and substance or medication intoxication or withdrawal. a history of delirium. see page 92. haloperidol) are used for psychotic symptoms. Delirium requires treatment of the underlying etiology. medical wards. B. C. Physical signs of delirium may include flushing. Medi­ cating symptoms should usually be avoided. and incontinence. cardiac failure). High-potency antipsychotics with low anticholinergic side effects (eg. fever. asterixis. Up to one-third of patients on surgical wards. Other risk factors include preexist­ ing brain damage. recent surgery. Delirium should always be suspected in patients on medical or surgical wards with psychiatric symptoms that are new or abrupt in onset. Perceptual and psychomotor disturbances also occur. infection.Significant deficit attention Less attention deficit Gradual onset (weeks to years) Chronic duration Gradual worsening symptoms of Abrupt onset (hours to days) Transient duration Fluctuating severity symptom Delirium . C.

such as. Social history: Ask about marital status. Family history: A history of suicide in the family increases the risk for suicide. and psychosis. and previous suicide attempts. spouse. multiple sclerosis. Ask about the perceived consequences of suicide and evaluate the patient’s beliefs about a desirable outcome. espe­ cially in the presence of comorbid psychiatric disorders. and other cluster B personality traits. Evaluate concurrent depressive symptoms. organic mental disorders. unemployment. financial trouble. and perceived consequences. and what factors influence the degree of determination. employ­ ment. treatments. . but also occurs with significantly increased rates in bipolar disorder. such as poor impulse control. means. Alcohol abuse and dependence is most commonly associated with suicide. anxiety. Ask about recent life changes. Ask about avail­ ability of lethal amounts of the substance abused and method of use. social support. Past psychiatric history: Ask about all past psychiatric symptoms. feel­ ings of hopelessness. and feelings of social isolation. diagnoses. Divorce. illness in the family. borderline personality disorder. Ask about anything the patient may feel they have to live for. antisocial personality disorder. such as writing a will or giving away personal belongings. Substance abuse history: Ask about all sub­ stances used. anxiety disorders. Huntington’s disease. interpersonal stress. Consider features of personality disorders in the assessment of suicidal ideation. Suicide is more likely to occur in patients just recovering from suicidal depression or in the few weeks to months follow­ ing discharge from the hospital. cardiovascular disease. poor social support. cognitive disorders. Assess the lethality of the plan. children. Always ask about the availability of weapons or medication to assess means. or legal problems. living alone. duration. or concern that hospitalization may interfere with an important event. and adjustment disorders. and ask about any preparations made. Ask about command auditory hallucinations. recent loss of a loved one. substance abuse. unstable relationships. family conflict. dementia and AIDS are all associated with depression and increase the risk of suicide. Negative consequences of suicide such as emo­ tional pain to the family should be discussed. and loss of a loved one are significant risk factors for suicide.History of present illness: The interview should begin with questions about current symptoms. and date of onset. plans. the ability to resist suicidal impulses. Epilepsy. Distinguish between passive and active suicidal ideation in assessing intent by asking about specific plans. Assess suicide potential by addressing intent. Also ask about family history of psychiatric illness and treatment. marital conflict. Substance abuse can some­ times be perceived as a form of suicidal behavior. and accidental overdose is a frequent cause of death in substance abusers. and assess evidence of plans for the future. substance abuse disorders. such as a trip to see children. legal trouble. such as financial benefit to the family. mood lability. or reunion with a deceased loved one. Heroin dependence is also associated with increased rates of suicide. living situation. Suicide is most commonly associated with major depression. Past medical history: Comorbid medical illness increases the risk of suicide. Patients with a history of suicide attempts are at greater risk. schizophrenia. or work. unsta­ ble self-esteem. illness in the family.

but may have in­ creased response latency. reliability is crucial in assessing commitment to safety. The patient may not under­ stand how their behavior will affect family and friends. adjustment disorder.” “angry. epilepsy. Suicide is most frequently associated with major depression. and approximately 15 percent of patients will eventually commit suicide. Thought content: Possible ruminations of guilt or obsessive thoughts about suicide methods. bipolar I disorder. Perform the mini-mental state exam in patients with suspected dementia or cognitive impairment related to depression. Epidemiology A. uncooperative. urinalysis with toxicology screen and blood alcohol level. schizophrenia and other psychotic disorders.” “hopeless. The patient wishes to die but may not understand the significance of the underlying illness.” “sad. Differential diagnosis: Axis I: Major depression. and rates among adolescents have increased signifi­ cantly in recent decades.” “worthless” Affect: Constricted.” Suicidality: Positive ideation with plans to jump in front of traffic. espe­ cially ones potentially lethal in overdose. Laboratory data: Complete blood count. Suicidal Ideation . and urine pregnancy test. Insight: Fair. Huntington’s disease. Mental Status Exam General appearance: Withdrawn. Suicide is the eighth-leading cause of death in the United States. chemis­ try. Women are more likely to attempt suicide.Discussion I. Axis II: Borderline and antisocial personality disorders. and cirrhosis. B. dysphoric. with poor eye-contact.Other medical problems that occur with mood disorders also increase suicidal risk and include: Cushing’s disease. Mood: “Depressed. dementia. Diagnostic testing: Testing should be done according to the differential diagnosis and de­ pending on symptom presentation. panic and other anxiety disorders. anorexia nervosa. and porphyria. with paucity of speech. Impulse control: Variable. history of attempts via overdose. commit to safety). Homicidality: Denies Sensorium/cognition: Memory and concentration may be impaired. One-third of people with schizophre­ nia will attempt suicide and an estimated 10 . cerebrovascular disease. Speech: Not spontaneous.000 commit suicide. Axis III: Neoplastic disease. cirrhosis. Approximately 12 peo­ ple per 100. soft. the patient may be unable to commit to contacting someone if feeling suicidal. Medications: Ask about all medications. Cushing’s disease. porphyria. A history of poor impulse control increases the risk of suicide. Reliability: Fair. congruent Thought process: Linear. multiple sclerosis. such as barbiturates. and tricyclic antide­ pressants. Perceptual: Possible auditory hallucinations with commands to “just do it” or “end it. alcohol and other substance abuse disorders. Judgment: Impaired. anticonvulsants. and men are more likely to complete suicide. slow. or he may be unable to agree not to hurt himself (ie. and anorexia nervosa. AIDS.

IV. benzodiazepines. methadone). or reunion with the dead. Feel­ ings of hopelessness are often a reliable predictor of suicide. Virtually all symptoms may be feigned. work.History Taking History of present illness: Current symptoms. prior suicidal behavior. such as localized. Treatment A. and distinguish between patterns of prior and current test performance. unemployment. Malingering . B. Clinical evaluation A. B. or generalized. Underlying medical and psychiatric illness must be appropriately addressed. In malingered psychosis. In malingered mental retardation. such as perseveration. date of onset. and family history of suicide II. or refuge from the police. hopelessness. Patients attempting to malinger psychosis often claim abrupt onset.Etiology. assess for discrepancies between level of educational or work achievement and reported intellectual func­ tioning. III. alcohol abuse. A previous history of attempts and a family history of suicide greatly increase risk. Patients should be questioned about their specific plans and availability of means. recent divorce or loss of a loved one. such as head injury. see page 92. degree of symptom exaggeration. hospital admission for free room and board. Assess degree of intentionality. and posttraumatic stress symptoms are the most common. Risk factors for suicide include depression. detail the nature of symp­ toms and onset. medications (eg. lack of social support. duration. and thought process disturbance. The majority of patients will reveal thoughts of suicide prior to at­ tempts. increased age (>45). Ask about the nature of amnesia. depression. such as avoidance of military duty. Suicide is associated with a combina­ tion of psychological and biological factors. Identify external incentives. effect on behavior. seizure disorders. and dissociative disorders. alcohol dependence. Other theories include ideas of self-punishment. C. escape from suffering. true psychosis.percent will complete the act. Also consider issues of secondary gain. Suicidal ideation must be thoroughly as­ sessed in the mental status exam. but amnesia. assess adherence to a known clinical picture. or jail. Malingerers are rarely able to feign thought process disturbance. selective. social responsibility. and typically are unaware of the social impairment that accompanies most cogni­ tive disorders. Reduced central seroto­ nin is associated with suicidal behavior. first exclude other possible causes of amnesia. psychosis. In malingered cognitive disorders. mental retardation. Freud believed that suicide represented aggres­ sion turned inward. such as financial gain. References. Patients with malingering amnesia often have selective amnesia with oppor­ tune timing. A specific plan. with . and degree of actual impairment (if any). Consider timing of onset and whether amnesia has a self­ serving component. In malingered amnesia. assess for impaired social functioning. cognitive disorders. and previous suicide attempts should lower the threshold for inpatient admission. Suicidal ideation typically requires inpatient hospitalization unless patients can reliably commit to safety. medical or psychiatric illness.

Delusional content is more likely to be paranoid or grandiose. the more convincing they are. unlike in true psychosis. Ask about a history of legal problems. Malingerers are less likely to be aware of the more subtle symptoms of depression or that depressive withdrawal extends to social and recreational activities as well as work. Social history: Ask about employment and source of income to assess possible issues of secondary gain. Perceptual: Unlike in true psychotic disorders. . Trunk and extremities may show marked restlessness as compared to facial expression. “I don’t know. and consider the possibility that patients are drug-seeking. Past medical history: Ask about medical prob­ lems and rule-out the possibility that complaints may be related to an underlying medical illness. Patients also tend to think that the more bizarre their behavior. malingered hallucinations are often continuous. or current warrants.symptoms that do not adhere to any known disor­ der. Suicidality: Suicidal thoughts and plans are frequently reported in attempts to gain hospital admission. Malinger­ ing is more common in military and prison popula­ tions. Past psychiatric history: Ask about past psychi­ atric diagnoses. but may be uncoop­ erative or overly dramatic. Thought process: Linear.” Affect: Congruent to reported mood. treatment. and malingerers often think that the more bizarre the delusion. Homicidality: Homicidal ideation is also a fre­ quent presenting complaint. Mental Status Exam General appearance: Calm. rather than intermittent. are not associated with delusions. and narcissistic personality traits. borderline. the more likely they are to be believed. arrests. decreased libido. Family history: Ask about family history of psy­ chiatric illness. and alternative medications. In malingered depression. Patients report an inability to ignore the voices and do not have strategies to diminish them. over-the­ counter. Medications: Ask about prescription. Malingerers may not know the subtle characteris­ tics of hallucinations beyond reporting “hearing voices” (see Table 7). and anhedonia. Mood: “Depressed. Malingerers may repeat questions to give themselves time to think of an answer and often say. substance abuse. Unlike true psychosis. Malingered mania may be accompanied by rapid speech that tires easily as the interview progresses. People with substance depend­ ence may seek hospital admission by feigning psychiatric symptoms. and hospitalizations. Speech: Slow to fast rate. irritability. There is no evidence of familial patterns in malin­ gering. ask about diurnal variation. but is rarely self-deprecating. Malingerers are more likely to have antisocial. histrionic.” Thought content: Delusions may be claimed to have sudden onset. and malingerers may threaten homicide. Thought disorder is very difficult to imitate. and are vague in their content. malingerers may be eager to call attention to their symptoms. and their behavior is not consistent with delusional content. Substance abuse history: Ask about substances abused. and suicidality. Volume also varies. Behavior is not likely to be consistent with delusions.

attempts to challenge or confront the patient may be met with anger or threats.Sensorium/cognition: Memory. True Hallucinations Malingered Hallucinations Continuous Originating from inside the head Vague or inaudible content Not associated with delusional content Stilted language is common Unable to use strategies to diminish voices Voices persist throughout sleep Commands are always obeyed Visual hallucinations are common Visual hallucinations may be seen in black and white Visual hallucinations may change if eyes are open or closed True Hallucinations Intermittent Originating from outside the head Relatively clear and spe­ cific content Associated with delusional content Stilted language is rare Able to use strategies to diminish voices Sleep provides a respite from the voices Commands are rarely obeyed Visual hallucinations are rare Visual hallucinations are seen in color Visual ha llucinations rarely change if eyes are open or closed Malingering . and neuropsychological testing as needed. Diagnosis: Axis I: Malingering Differential diagnosis: Conversion disorder. malingerers may give approximate answers to simple questions (eg. concentration. urine toxicology screen. The patient understands that symptoms are being intentionally produced. and intellectual impairment are often feigned. Adults with antisocial personality disorder and children with conduct disorder are more likely to lie about symptoms for external incentives. Judgment: Fair. Diagnostic testing: Skull x-ray to rule out head trauma. Malingering is estimated to occur in approxi­ mately one percent of mental health pa­ tients. chemis­ try. magnetic resonance imaging. and be­ tween ten and 20 percent among criminal defendants. B. Insight: Intact. and Ganser’s syndrome. Other tests may include a polygraph to assess physiological stress and the Minnesota Multiphasic Personality Inventory (MMPI) to detect inconsistent answers. The other cluster B personality disorders are also more frequently associ­ ated with malingering. Reliability: Limited. Malingerers are likely to contradict themselves in their symptom reporting. II. The degree of impairment in judgment will vary on an individual basis. factitious disorder. Etiology A. Malingered vs. Laboratory data: Complete blood count. other somatoform disorders. . Table 7.Discussion I. Malingering is the intentional production of false or grossly exaggerated symptoms that is motivated by external incentives. Epidemiology A. 2 + 2 =5). Impulse control: Potentially impaired. five percent in the military.

Malingerers may experience difficulty suppressing correct answers to questions. References. Malingering is suspected when the clinical presentation is characterized by symptoms that are vague and overly dramatized and not consistent with known clinical conditions. Because of its association with antisocial personality disorder. There may be a significant discrepancy between the rehearsed and calm facial expression of a malingerer as compared to their body movement and behavior. B. Clinical features A. external incen­ tives should be addressed and alternate means of achievement explored. and obtaining drugs. Comorbid psychiatric illness should be assessed and treated. G.B. fidgeting. Malingering should always be suspected whenever specific external incentives. If malingering is confirmed. . III. Extending the duration of an interview may facilitate the diagnosis by exhausting the patient’s ability to malinger. Malingering has an understandable motive that can be identified only after true medical or psychiatric illness has been ruled out. and the history may reveal past episodes of injury. avoiding work. D. are present. and lack of cooper­ ation during an interview may indicate malin­ gering. obtaining financial compensation. C. some theories propose hypoarousability as a predisposing factor. such as avoiding work or the military. The most frequent reasons for malingering are avoiding military duty. see page 92. E. evading criminal prosecution. They should be approached with clinical neutrality and confronted only after careful assessment. Malingerers should not be admitted to the hospital unless true illness cannot be ruled out. These patients often display a marked dis­ crepancy between claimed disability and objective findings. Management F. Restlessness. Findings may appear consistent with self-inflicted injury. IV.

Social history: History of abandonment. and assessment of promiscuity. arrogance. self-entitlement. fear of being alone. employment. impulsivity.image. diagnoses. heroin. deceitfulness. infection. mood swings. and outpatient follow-up. associated distress. neglect. and substance abuse occur with increased frequency in patients with cluster B personality disorders. . If antisocial personality disorder is suspected. treatments. irritability. and dissociative symptoms. Family history: Substance abuse and major depressive disorder occur with increased fre­ quency among first-degree relatives of patients with borderline personality disorder. and current medical problems. anxiety disor­ ders. and current warrants should be assessed. Evaluate for comorbid depressive symptoms and substance abuse or dependence. such as derealization and depersonalization. childhood history of illness. relationships. anxi­ ety. date of onset. duration. a history of legal problems. brain damage. Alcohol abuse in particular is associated with antisocial personality disorder. poor self. rape. psychosocial stressors. hypnotics. Antisocial traits may also be more likely to occur in family members of patients with antisocial personality disorder. grandiosity. and lack of remorse. self-esteem. aggressive­ ness. marijuana. disregard for the safety and rights of other people. and empathy. incarceration.Dramatic or Emotional Personality Disorders . suicidal ideation. arrests. and analgesics. anger. Substance abuse is frequently seen in patients with borderline and antisocial personality disor­ ders. Past psychiatric history: Past hospitalizations. somatization disorder. Current living situa­ tion. sedatives. depressed mood. History of suicide attempts or self-mutilation. dependency. physical or sexual abuse. Depression. hallucinogens. Past medical history: Perinatal complications. irritability. anxiolytics. and exposure to substance abusing parents. impaired sense of identity. amphetamines. sexual history. Histrionic personality disorder should be assessed by asking about need for attention and flirtatious and seductive behavior. Narcissistic personality disorder is suggested by a sense of self-impor­ tance. Antisocial personality disorder should be assessed by asking about impulsivity. history of head trauma. Borderline personality disorder should be as­ sessed by asking about interpersonal relation­ ships. self-mutila­ tion. hostility. Medications: All prescription and over-the coun­ ter medications. and functional impairment. Suspected antiso­ cial personality disorder should be assessed by asking about a history of conduct disorder symp­ toms beginning before age 15 and a history of attention-deficit/hyperactivity disorder. cocaine. Substance abuse history: Alcohol. ask the patient if they feel calm or relieved following self-injurious behavior.History Taking History of present illness: Current symptoms. feelings of emptiness or abandonment.

exces­ sively ingratiating. and narcissistic personality disorder. irritable. in colorful clothing. generalized anxiety disorder. Suicidality: Passive (no plan). histrionic. but with appropriate fund of knowledge. The patient does not under­ stand how behavior affects other people. Antisocial and borderline personality disorders . Speech: Variable volume. alternates between slow and rapid rates. II. The patient does not recognize the nature of the illness and may relate symptoms to environmental stressors alone. The cluster B personality disorders are borderline. The most frequently encoun­ tered personality disorders on inpatient psychi­ atric units fall into the dramatic and emotional cluster. intact memory. Etiology. substance-in­ duced mood disorder. and posttraumatic stress disorder. Homicidality: Vague homicidal thoughts may occur in borderline personality disorder.” “depressed. Hamilton Rating Scale for Depression. also called cluster B.Discussion I. well­ groomed. adjustment disorder. expansive. Impulse control: Limited. Epidemiology. The mini­ mental state exam is usually normal. and antisocial personality disorders. good concentration. antisocial. or vague suicidal ideation that is difficult to characterize. such as the Rorschach and the Thematic Apperception Test. and pregnancy test. Differential diagnosis: Bipolar I and II disorders. thyroid function tests. and the CAGE questionnaire are often positive. Goal-directed. Patients may attempt to hurt themselves during the course of the interview. Cluster B personality disorders are more com­ mon in women with the exception of antisocial personality disorder. Thought content: Patients may be preoccupied with somatic complaints and perceived medical problems. or command auditory hallucinations. visual. RPR. but vague. histrionic. History is vague. and inappropri­ ate at times. Dramatic or Emotional Personality Disorders .Mental Status Exam General appearance: Well-dressed. Judgment: Limited. dramatic. Reliability: Poor. Thought process: Linear. blood alcohol level. particularly if they perceive that their symptoms are not being taken seriously. Perceptual: Patients may endorse auditory. but thoughts may be much more explicit in antisocial personality disorder. the details of which are difficult to elicit. Diagnostic testing: Projective psychological testing. chemis­ try. major depressive disorder. Sensorium/cognition: Alert and oriented. somatoform disorders. narcis­ sistic. active (with a specific plan). Insight: Limited. Diagnosis: Axis II: Borderline.” Affect: Labile. well-related. Personality disorders are likely caused by an interaction between biological predisposition and environmental influence. urine toxicology screen. seductive. thinking is concrete. and without signs of psychomotor retardation or agitation. Laboratory data: Complete blood count. and symptom reporting is inconsistent. Mood: “Very bad. such as pain and dehydration. Patients may also report the feeling of being outside their body (depersonalization).

III. Patients may report that the pain of self­ mutilation serves to bring them back to reality during a state of identity diffusion or dissociation. Personality disorders are diagnosed on Axis II. . and clinicians tend to defer their diagnosis until acute issues have resolved. They constantly require attention and may misinterpret superficial relationships as being more intimate than they are in reality. F. They are difficult to assess in the context of acute Axis I pathology. Borderline personality disorder patients exhibit a clinical tetrad of labile affect. but express themselves in a dramatic fashion. and volatile interpersonal relationships. IV. deviates from cultural standards. Personality disorders are defined by a per­ vasive pattern of behavior that is persistent over time. and have a lack of remorse about their behavior. and frequently have a history of vio­ lence and other criminal activity. Mood stabilizers and antipsychotics are used for mood lability and behavioral control. and causes significant distress or functional impairment to the patient. E. References. but these disorders are usually very difficult to treat. poor impulse control. These patients had conduct disorder as a child. Antisocial personality disorder patients are often manipulative. Psychopharmacologic treat­ ment of personality disorders is limited. B. Narcissistic personality disorder patients appear extremely self-entitled with a grandi­ ose sense of importance. Histrionic personality disorder patients have shallow emotional responses. Histrionic and borderline personality disorders are asso­ ciated with a history of physical or sexual abuse. Clinical evaluation A. Patients with personality disorders may require inpatient hospitalization for suicidality or severe impairment in function­ ing.may demonstrate familial inheritance. unsta­ ble self-image. Narcissistic patients are preoccupied with selfish pursuits and may be unrealistically ambitious. D. anxiety. Treatment usually consists of long-term psychotherapy. see page 92. Prognosis varies individually according to level of functioning and the presence of social support. deceitful. B. but actually suffer from low self-esteem and are extremely sensitive to criticism. C. C. Dissociative phenomena of depersonaliza­ tion and derealization may occur and con­ tribute to feelings of identity confusion.Treatment A. although antidepressants such as selective­ serotonin reuptake inhibitors may be used to treat comorbid depression. and impulsivity.

affective lability. Associated symptoms may include agitated behavior. seizures. Assess language development. Social history: Family relationships. and non-spontane­ ous. and apraxic gait in females may suggest Rett’s disorder. compulsive behavior. motor and vocal tics). Ask specifically about comorbid obsessive-compulsive symptoms. poor impulse control. and special education. with poor eye contact. Perceptual: The presence of hallucinations should raise suspicion of childhood onset schizo­ phrenia. disengaged. and Tourette’s disorder (eg. Recent stressors. and developmental disorders in relatives. and social relationships at day care. changing school. Speech: Possibly incomprehensible. Past psychiatric history: Previous hospitaliza­ tions. recipro­ cal play. biting. Past medical history: Perinatal complications. Affect: Constricted. rocking in place.Developmental Delay . tuberous sclerosis.History Taking History of present illness: Ask about current symptoms. easily irritable. neonatal anemia. outpatient treatment and medications. or home. Mood: Apathetic. Family history: Psychiatric. peculiar rhythms. shallow. and impaired social interaction may occur more frequently in family members. phenylketonuria. with echolalia and perseveration. developmental milestones. exposure to marital conflict. such as rocking and spinning. hand wringing. Developmental history: Perinatal history. uncooperative. and recent stressors or changes in the patient’s life. but screening questions should be asked. age of onset. and grimacing. although self-injurious behavior may appear when the patient feels frustrated during the course of the examination. and neurological lesions all occur with greater fre­ quency in children with developmental disorders. stereotypic behaviors. hyperactivity. pervasive developmental disorders. school. Motor incoordination. Thought process: Possibly incoherent. Suicidality: The patient usually denies suicidal thoughts. duration. . and self-injurious behavior (eg. depressed or irritable mood. head banging). and birth of a sibling. Homicidality: Denies. attention deficit. Always consider accidental ingestion. moving. Mental retardation. and unpredictably labile. temper tantrums. scratching. school achievement. screeching. delayed language develop­ ment. such as hand wringing. Medications: Prescribed medications and over­ the-counter. low frustration toler­ ance. babbling. learning disorders. past diagnoses. Thought content: No delusions present. social interaction. current living situation. and rigid adherence to specific routines. fragile X syndrome. hyperactivity. neurological. respiratory distress syndrome. specific trauma or stressors. stereotypic movements. not pervasive developmental disorders. congenital rubella. Substance abuse history: Substance abuse is rare in young children. Mental Status Exam General appearance: Inattentive. such as divorce of parents. eye contact. preoccupation with inanimate objects.

neuropsychological testing audiometry. Child­ hood Autism Rating Scale. such as head banging. chemis­ try. learning disorders. teachers. childhood disintegrative disorder. commu­ nication disorders (eg. urinalysis. and congenital deafness. with temper tantrums and self­ injurious behavior. psychosocial deprivation. Judgment: Limited. thyroid function tests. Reliability: Limited. chromosomal analysis. The patient does not understand the nature of his illness. and short attention span. and lead testing. mixed receptive-expressive language disorder). The patient becomes easily angered. Cognitive abilities may be impaired by mental retardation. Differential diagnosis: Mental retardation with behavioral symptoms. childhood onset schizo­ phrenia. and electroenceph­ alography. and Rett’s Disorder. Impulse control: Limited.Sensorium/cognition: Alert. and other caregivers for informa­ tion. The patient lacks understand­ ing of behavior’s consequences and how it affects others. Interviewers must rely on family. Vineland Adaptive Behavior Scale. . Autism Behavior Checklist. concrete thinking. egocentricity. screening for phenylketonuria and other inborn errors of metabolism. selective mutism. Asperger’s disorder. magnetic resonance imaging. Diagnosis: Axis I: Autistic disorder. Diagnostic testing: Autism Diagnostic Interview (ADI). increased distractibility. Insight: Limited. Laboratory data: Complete blood count.

Antipsychotics may effec­ tively reduce agitation. Patients with Rett’s disorder eventually become wheelchair bound and lose all language ability. D. impaired social interaction. ritualistic behavior. The four pervasive develop­ mental disorders are autistic disorder. and lim­ ited behavioral repertoire. . II. There is significant evidence linking autism to heritable neurological disorders. such as metal. References. Audiometry should be per­ formed to rule out deafness. irritability. Approximately two-thirds of patients with autistic disorder have mental retardation. III. Autistic disorder is the most common and affects approximately 1. IV.Discussion I. and compulsive. lifelong course. childhood disintegrative disorder. but with an unclear mode of transmis­ sion. ataxia. and affected children tend to suffer a chronic. reducing odd behavior.7 out of 1000 children. The etiology of autism is genetic in origin. Pharmacotherapy is useful for symptom­ atic management. E. Treatment A. and limited behavioral repertoire. Clinical evaluation A. and mental retarda­ tion. C. Selective serotonin reuptake inhibitors are used for impulsivity. Behavioral therapy and educational methods are focused on increasing social interaction. Epidemiology. and Asperger’s disorder. Autistic disorder is characterized by the clinical triad of impaired language develop­ ment. Clonidine is used for hyperactivity. and stereotypic movement. perinatal complications. and developing language. It is typically diagnosed by the age of three. Rett’s disorder is characterized by symptoms of autism in addition to progressive neurologi­ cal signs. Inpatient hospitalization may be re­ quired for agitated or self-injurious behav­ ior. People with pervasive developmental disorders may require residential care with full-time supervision. and self-injurious behavior.Pervasive Developmental Disorders . Improvement may occur over time. impaired social interaction. The most com­ mon initial feature is delayed language development. Rett’s disorder occurs only in girls. see page 92. and one-third may develop a seizure disor­ der. Childhood disintegrative disorder is characterized by normal development for two years. C. B. Comorbid obsessive-compulsive symp­ toms are common in autistic disorder. Rett’s disorder. occurring more frequently in boys. Asperger’s Disorder is a less severe form of autism where language development remains intact. such as apraxia. aggression. Etiology. Pa­ tients tend to become preoccupied with inanimate objects. and they may become easily frustrated or anxious if ritualistic behaviors are interrupted. B. followed by a loss of acquired language.

domestic violence. vocal tics. fidgeting. Social history: Family relationships. amphetamines (eg. cocaine. and interrupting. hypoxia. such as substance abuse. grunting. fear or dislike for school or social situations. pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS). and shouting. .Attention-Deficit and Hyperactivity . Assess the presence of depression. suicidal ideation. Assess symptoms of difficulty listening and following instructions. hallucinogens. Thought content: No active delusional content. Tourette’s disorder. Low birth weight. conduct disorder. school. ADHD. childhood lead expo­ sure. constant need for attention. hyper­ activity. Ask about the presence of somatic symptoms. special education. phobias. theophylline. Ask about past hospitaliza­ tions. Past medical history: Prenatal exposure to toxins. medication. marital conflict. anxiety. duration. fidgeting. easily distracted. Grade in school. increased rate. date of onset. irritability. Substance abuse history: Alcohol. reluctance to attend school. such as nausea and vomiting. and head trauma. but with some difficulty following a coherent train of thought due to problems concentrating and distractibility. crystal meth. heroin. raising eyebrows. Past psychiatric history: Previous psychiatric diagnoses. difficulty sleeping away from home. history of mood lability. and caffeine can cause symptoms of attention deficit and hyperac­ tivity. hyperthyroidism. learning disorders. bipolar disorder. excessive fear of being alone. cigarette smoke. irritability. dysphoric. learning disorders. and violence. and cigarettes. and impulsivity. mumbling rhythm. Determine in which environments symptoms occur (eg. benzodiazepines. Medications: CNS stimulants. and outpatient psychiatric treatment. nightmares.History Taking History of present illness: Current symptoms. neck twisting. such as persistent worry. social relationships with peers. school performance. alcohol. Ask about inattention. but appropriate. depressive symptoms. belching. Mental Status Exam General appearance: Restless. seizure disorder. distractibility. antisocial personality disorder. antidepressants. Tic disorders occur with increased frequency in family members of children with ADHD. home). phenobarbital. unco­ operative. cocaine. divorce. Perceptual: Denies hallucinations or illusions. obsessions. sexual abuse. forgetfulness. may express frustration. Mood: “Fine” or “depressed. carbamazepine. ecstasy. crank). and emotional neglect. depres­ sion. Thought process: Linear and goal-directed. Family history: Psychiatric illness in family members. marijuana. divalproex. and sexual behavior. and conduct disorder are all common comorbid conditions. poor eye-contact. physi­ cal abuse. adoption. Motor tics. and panic. talking excessively. compul­ sions. speed. identifiable stressors. Obsessive-compulsive symptoms. lead.” Affect: Irritable. Ask about anxiety symptoms. Speech: Decreased volume. blinking. irritability.

Thinking may be concrete. oppositional defiant disorder. carbamazepine. and cigarettes. and Wilson’s disease. lead. Patient inconsistently reports symptoms. These disorders must first be excluded because treatment varies dramatically. Etiology. Epidemiology. thyroid function test. learning disorders. streptococcal infection. Homicidality: Denies homicidal ideation. but both genetic and environmental influences have contributing roles. learning disorders. zinc protoporphyrin (ZPP) to detect lead exposure. Tourette’s disorder. Neurological: Seizure disorder. theophylline. due to young age. physical or sexual abuse. Tourette’s disorder. Clinical evaluation A. such as at school and at home. Medical: Hyperthyroidism. Conners Hyperactivity Scale.Discussion I. barbitu­ rates. The etiology of ADHD is unclear. glutamate. malnutrition. Diagnostic testing: Neuropsychological testing. and because the psychostimulants used to treat ADHD may . Age appropriate. separation anxiety disorder. motor compul­ sions associated with obsessive-compulsive disorder. and symptoms must occur before the age of seven. Symptoms must also occur in at least two settings. posttraumatic stress disorder. substance-induced (eg. serotonin. and urine toxicology screen. GABA. Insight: Limited. major depression. brain damage. teratogenic effects of alcohol. Diagnosis: Axis I: Attention Deficit/Hyperactivity Disorder. and norepinephrine. oppositional defiant disorder. sub­ stance abuse. benzodiazepines. caffeine). Judgment: Fair. Recent attention has been focused on the specific roles of dopa­ mine. Other psychiatric disorders that are easily mistaken for ADHD include conduct disor­ der. The diagnosis of ADHD requires at least six symptoms of inattention and/or hyperac­ tivity for at least six months. Attention-deficit/hyperactivity disorder (ADHD) is a common illness that accounts for up to half of child psychiatry outpatient visits and inpatient hospitalizations. Reliability: Limited. anxiety disorders. and central nervous system infection. amphetamines. impaired concentration. no apparent language deficits. Attention-Deficit/Hyperactivity Disorder . pregnancy test. and normal oppositional behavior. Sensorium/cognition: Alert and oriented. and bipolar disorder. Laboratory data: Complete blood count. cocaine. This disorder occurs more frequently in boys than girls. B.Suicidality: No active suicidal ideation. intact memory. lead poisoning. and Achenbach Child Behavior Checklist. pseudoephedrine. bipolar disorder. chemis­ try. ADHD is usu­ ally diagnosed by five years of age. and prevalence estimates range from 3 to 10 percent of school-age children. Impulse control: Patients may get up frequently during the interview and even walk away. major depression. III. Differential Diagnosis Psychiatric: Conduct Disorder. II. mental retarda­ tion. normal hyper­ activity.

seizures. Family history: Antisocial personality disorder.History Taking History of present illness: Current symptoms. heroin. Substance abuse history: Substance abuse is frequently seen with Conduct Disorder. bullying. substance abuse. Theft. Ask about comorbid psychotic symptoms. past hospitalizations. Gang involvement. conduct disorder. General defiance of authority figures. Treatment of ADHD consists of psychostimulants for inattention. stealing. Neuropsychological testing is often required to rule out an underlying learning disorder. Psychosocial therapies include individual psychotherapy and behavior modification techniques that help the child to reduce anxiety and improve self-esteem. fighting. School level. frequent arguing. Assess symptoms of depres­ sion and mania to rule out a comorbid mood disorder. developmental disorders. and special education. hostility. clonidine for hyperactivity. panic attacks. adoption.significantly exacerbate symptoms of other disorders. and juvenile detention. . Past medical history: Perinatal complications. income. Ask about alcohol and other substance abuse in family members. divorce. arrests. and neglect. and allergies. Disruptive Behavior . learning disorders.Treatment A. head trauma. and pain medication. Medications: Include all psychiatric. medications. impulse control problems. Ask about alcohol use. see page 92. Aggression towards people. cocaine. and fire setting. and schizophrenia all occur with greater frequency in family members of children with conduct disorder. incarceration. domestic violence. and outpatient psychiatric treatment. caretakers. phobias. attendance. date of onset. destruction of property. lying. selective-serotonin reuptake inhibitors for impulsivity. and blaming others for misbehavior. and mental retardation may all occur with increased frequency in patients with conduct disorder or oppositional defiant disorder. past illness. ignoring parental curfews. depression. and antipsychotics to target aggressive symp­ toms. school person­ nel and pediatricians should be interviewed. Attention deficit. learning disorders. communication disorders. cheating. temper tantrums. legal history. running away from home. Family members. psychosocial stressors. Social history: Family relationships. performance. amphet­ amines. barbiturates. ADHD. rule violations. foster care. B. IV. such as auditory hallucinations or paranoid delusions. hyperactivity. Inpatient admission may be required for agitated or aggressive behavior. general. C. bipolar disorder. weapon use. Past psychiatric history: Previous psychiatric diagnoses. duration. physical or sexual abuse. sexual assault. marijuana. depressive or manic episodes. and non-prescription medications. References. and school truancy.

” “good.” or “angry. Clinical evaluation A. Conduct disorder greatly increases the risk of developing antiso­ cial personality disorder. Aggres­ sive and violent behavior in general may be associated with decreased serotonin metabolite (5-HIAA) in cerebrospinal fluid. Oppositional defiant disorder is a less severe form of conduct disorder defined as a recurrent pattern of defiant and hostile behavior towards authority figures. irritable. It is estimated to be present in more than half of all juvenile delinquents and incarcerated youth. Impulse control: Impaired. and poorly related. Diagnostic testing: Neuropsychological testing. learning disorders. Etiology. oppositional defiant disorder. Biopsychosocial factors play a signifi­ cant causative role in conduct disorder. The patient may deny all symp­ toms and not recognize the presence of a prob­ lem. Oppositional behavior may be normal and adaptive. The patient may demonstrate destructive or threatening behavior. uncooperative. and urine toxicology screen. Mood: “Fine. Reliability: Limited. and is not associated with legal problems. may occur in severe cases. but congruent and full­ range. dysthymia. Speech: Normal rate. The patient lacks understand­ ing of how his behavior affects others. Conduct Disorder . III. these . Homicidality: Denies homicidal ideation and may be flippant or dismissive when questioned about violence history. ADHD. major depression. and it is usually diagnosed before 13 years old. The patient may be demeaning or challenging toward interviewer. Diagnosis: Axis I: Conduct disorder. Sensorium/cognition: Alert and oriented. and the Achenbach Child Behavior Checklist. Conduct disorder is the most common reason for an inpatient hospitalization or outpatient visits in children and adolescents. such as paranoid ideation. Perceptual: Hallucinations are unlikely. but may also occur as a pathological entity and possible precursor to conduct disorder. or attention defi­ cit/hyperactivity disorder. hostile. Conduct disorder is more prevalent in boys. thyroid function tests. electroencephalography. Thinking is concrete. rhythm. substance-induced behavioral symptoms. and normal oppositional behavior. The hallmark characteristic of conduct disorder is disruptive behavior that violates the rights of others and persists for at least 12 months. Laboratory data: Complete blood count. Thought process: Linear and goal-directed.” Affect: Dysphoric. Differential diagnosis: Bipolar disorder. Thought content: Delusional thinking. In oppositional defiant disorder. II. Suicidality: No active suicidal ideation elicited. The patient minimizes symp­ toms and lies about past behavior. Judgment: Limited. While there is clear genetic transmission of aggressive and violent tendencies. but cognitive abilities may be impaired by mental retardation. impulse control disorders.Mental Status Exam General appearance: Suspicious.Discussion I. Insight: Limited. and volume. learning disorders. behavior does not violate the rights of others. Epidemiology. B. chemis­ try. pregnancy test. mental retardation.

Early symptoms of bipolar disorder may be initially misdiagnosed as conduct disor­ der. the possibility of psychotic symp­ toms must also be assessed. C. previous weight loss episodes. suicide attempts. enemas. stealing. peer relationships. Substance abuse history: Amphetamines. vomiting or purging. date of onset. heroin. and actual weight loss. anxiety symptoms. binge-eating behavior. Previous episodes of binge-eating or purging behavior. Impulse control problems. dental caries. dieting. food rituals. and impulse control problems. Ask about depressive symptoms. Eating Disorders . domestic conflict. Selective serotonin reuptake inhibitors may be effective for impulsivity and irritability. and sexual maturity. school achievement. Past psychiatric history: Past hospitalizations. bulimia. mood stabilizers. anxiolytics. Treatment A. References. Social history: Family relationships.History Taking History of present illness: Ask questions about current symptoms. or clonidine are used for aggression. see page 92. fear of weight gain.Psychotherapy with behavioral training is effective at reducing impulsive and ag­ gressive behavior. and sleep disturbance. In severely violent cases of conduct disorder. and need for control. cocaine. self-mutilation. separation from parents. gastrointestinal distress. divorce. medications. preoccupation with food. Antipsychotics. mood lability. appetite suppressants. and marijuana. checking. Ask about medications. Amenorrhea. and substance abuse. stealing. suicidality. parenting styles. poverty. Formal psychiatric evaluation and clearance may also be required before the child is allowed to return to school. and obsessive-compulsive disorder are more . and perceived societal pressure to be thin. Attempt to gauge degree of independence. clinical depres­ sion. and excessive exercise. history of depres­ sion. C. past suicide attempts.behaviors usually occur in the context of strict or punitive parenting styles. Family history: Anorexia. school truancy. sexual promiscuity. somatic complaints. hypnotics. enemas. including family members and peers. diuretics. ipecac.Inpatient hospitalization becomes neces­ sary if patients pose a danger to them­ selves or other people. The family must be in­ volved. precipitants. diuretics. abuse of laxatives. B. obsessive-compulsive behavior.Treatment for disruptive behavior re­ volves around firm limit-setting and estab­ lishing predictable consequences for breaking rules. IV. abuse. Ask the patient about their perception of body weight and self­ image. and laxatives. and parents should be taught techniques to facilitate appropriate behav­ ior. alcohol. or substance abuse among family members. such as fear of contamination. such as sedatives. and outpatient treatment. analgesics. and recent dieting. Assess comorbid obsessive-compulsive symp­ toms. perfectionism. duration.

likely to occur in family members of patients with eating disorders. Kleine-Levin syndrome. potentially hostile. body dysmorphic disorder. cholesterol. patients may be convinced that they are overweight despite significant weight loss. anorexia and weight loss associated with medical illness or malignancy.” Affect: Irritable. Diagnosis: Axis I: Anorexia nervosa and bulimia nervosa. dysphoric. with intact memory and concentration. borderline personality disorder with binge eating. gastric and esophageal erosion. Impulse control: Limited. edema. somatization disorder. obsessive-compulsive disorder. Epidemiology. medical. psychotic disor­ ders with delusional thinking revolving around food. over-the-counter. liver function tests. Perceptual: No auditory or visual hallucinations. unconcerned. fearful of gaining weight. dexamethasone-suppression test. Klüver-Bucy syndrome. Eating disorders typically first present during adolescence. chemis­ try. salivary gland enlargement. Homicidality: Denies. and child-like. Binge-eating and purging behavior persists despite consequences. Thought content: Preoccupied about body weight and image. Differential diagnosis: Clinical depression.Discussion I. Assess medical complications related to weight loss and purging activity. although most patients are alert and oriented. Speech: Normal rate. Patients may deny all symptoms or the presence of a problem. orange colored skin. Mental Status Exam General appearance: Cachectic. Patients are often extremely secretive and do not fully disclose extent of symp­ toms. obsessional or bizarre thinking revolving around food. osteoporosis. Anorexia Nervosa and Bulimia Nervosa . Judgment: Limited. and dismissive or minimizing of serious symptoms. Suicidality: Suicide occurs more frequently in patients with eating disorders. with lanugo hair. pregnancy test. and urine toxicology screen. and electrocardiography. They occur more frequently in women and are associated with significant morbidity and mortality secondary to . Mood: “Fine. Past medical history: Ask about a history of malignancy. seizures. Insight: Limited. and alternative medications. thyroid function tests. Language deficits or disturbance in abstract thinking are usually not present. amylase. and suicidal ideation must be thoroughly assessed. cardiac arrhythmias. Weight loss continues de­ spite medical complications. amenorrhea. rhythm. Laboratory data: Complete blood count. cardiomyopathy secondary to ipecac toxicity. carotene level. cold intolerance. evasive. inappropriate at times. Reliability: Limited. Thought process: Linear and goal-directed. Sensorium/cognition: Cognition may be affected by weight loss. uncooperative. Diagnostic testing: Height and weight measure­ ment. and dental caries. difficulty concentrating and fatigue. and volume. Medications: Ask about psychiatric.

patients have a dis­ torted body image and are frequently respond­ ing to societal pressures to be thin.History Taking History of present illness: The date of first and last use of the substance should be defined. or gastroin­ testinal complications. Clinical evaluation A. C. Etiology. diarrhea. work. driving). see page 92. C. and psychosocial stressors. IV. vomiting. Failure to fulfill obligations at home. II. dysphoria. weekly. Treatment A. daily. amount of substance used.Hospitalization may be required in pa­ tients with eating disorders for medical stabilization of electrolyte imbalance. becoming Annoyed by people who criticize the alcohol use . Barbiturate abuse . Screening for alcohol abuse should be accomplished by asking about feeling the need to Cut down. hallucinations. If substance dependence is suspected. rhinorrhea. lacrimation. irritabil­ ity. The history should assess the full extent of symptoms despite the tendency for these patients to remain extremely secretive about their eating behavior. ask about the need for increasing amounts of the substance to produce intoxication (tolerance) and withdrawal symptoms. nausea. III. ask about shakes. starvation may be an effort by patients to control their bodies in response to overly controlling parents or the lack of a sense of autonomy. vomiting. route of administration. psychotic symptoms.After medical stabilization and restora­ tion of nutritional status. monthly. bulimia nervosa may respond to antidepressant treatment even in the absence of depressive symp­ toms. Sedative. Longest period of sobriety.Cognitive behavioral therapy is effective in the treatment of eating disorders. For cocaine withdrawal. Determine the frequency and patterns of use. hypnotic. D. and substance use in situations that are danger­ ous (eg. muscle aches. For opioid withdrawal. For alcohol withdrawal. anxiety. and insomnia. The onset of anorexia or bulimia may be the result of difficulty adjusting to develop­ mental changes of puberty and adolescence. excessive concern about body weight. In anorexia. agitation. insomnia. ask about anxiety. B. and insomnia. Guilt about drinking. dehy­ dration. triggers. References. seizures. and anxiolytic withdrawal may include tremors.medical complications from weight loss and purging activity. and lack of menstruation for at least three consecutive cycles. and orientation. In bulimia. but maintain normal body weight. Anorexia nervosa is characterized by refusal to maintain body weight above 85 percent of ideal. Substance Use . and Eye openers to steady nerves in the morning (CAGE questionnaire). circumstances of use. cardiac arrhythmias. B. patients are typi­ cally treated with a combination of psycho­ therapy and pharmacotherapy. Patients with eating disorders have dis­ turbed eating behavior. Patients with bulimia nervosa binge eat and experience a loss of control over eating behavior. and seizures. Al­ though anorexia nervosa is typically resis­ tant to pharmacotherapy. and a distorted body image. ask about dysphoria. substance-related legal problems. a preoccupation with food. nausea. yawning. or school.

and spider nevi. anxiety disorders. and borderline personality disorder occur with increased frequency in people with substance abuse disorders. marijuana. cardiac arrhythmias. gynecomastia. hepatosplenomegaly. ascites. Substance abuse history: Ask about all sub­ stances used: alcohol. family history of suicide and psychiatric illness. anx­ ious. Medication toxicity may mimic the symptoms of substance intoxication. cocaine. hospitalizations. gives irrelevant answers to questions. Assess physical signs of alcoholism. Mental Status Exam of the Intoxicated Patient General appearance: Disheveled. or tactile/olfactory hallucinations. amnesia. such as ulceration of the nasal septum. and neuropathy. such as HIV.should be carefully assessed because withdrawal is potentially fatal. Suicide is more frequent in people with substance abuse disorders. Family history: Alcohol and substance-related disorders in first-degree relatives. past psychi­ atric diagnoses and treatment. hypertension. Patients may be dismissive of concerns about their drug use. substance abuse treatment pro­ grams. pancreatitis. employment. gait is ataxic. such as mood lability. benzo­ diazepines. irritability. history of violence or criminal activ­ ity. Mood disorders. Perceptual: Depending on the level of intoxication or extent of withdrawal. level of education. anxiety disorders. and breath may smell of alcohol. and words are sometimes incomprehensible. and seizures. and sleep disorders. anxiety. mood disorders. Complications from intravenous drug use. Complica­ tions from cocaine use. Mood: “Depressed. may appear older than stated age. sexual dysfunction. restless with mild shaking of the hands. Past psychiatric history: Past history of sub­ stance abuse. dementia. poor registration and recall.” Affect: Constricted to the dysphoric range. or osteomyelitis. Thought process: Circumstantial. gastritis. psychosis. Homicidality: Possible homicidal ideation with plans that vary in specificity. patients may have audi­ tory. Substance abuse may also induce delirium. Sub­ stance abuse increases the risk of violence to­ wards others. Past medical history: Ask about medical compli­ cations from alcohol abuse. antisocial personality disorder. visual. cellulitis. poorly groomed. physical or sexual abuse history. such as liver disease. nutritional deficien­ cies. and analgesics. cardiomyopathy. Question the patient and family members about behavioral changes. ag­ gressiveness. Social history: Living situation. Thought content: Paranoid ideation and ideas of reference occur. increased volume. heroin. poor concentration. peptic ulcer disease. so ideation and plans need to be assessed. and impaired judgment. impulsivity. but appropriate. medications. Speech: Slurred rhythm. hallucinogens. malodorous. Sensorium/cognition: Inconstant alertness with variable degrees of orientation to place and time. A history of attention-defi­ cit/hyperactivity disorder and conduct disorder increases the risk of developing an alcohol-related disorder. Medications: All medications including prescrip­ tion and over-the-counter. amphetamines. . such as varices. hepatitis. normal rate. Suicidality: Substance abuse increases suicidal risk.

and urinalysis with toxicology screen. Ap­ proximately 20 percent of men and 10 percent of women have abused alcohol at some point in their lifetime. behavior may be aggressive and unpredictable. and electrocardiogram. Etiology. abuse. B. III. they have substance-related legal problems. hallucinogen-related disorders.The patient may refuse to cooperate with a mini­ mental state exam. liver function tests. and polysubstance dependence. and dependence may develop in up to half of these cases. parent or peer influ­ ences. inhalant-related disorders.” seizures. Epidemiology. Judgment: Impaired. and anxiety disorder. coagulability panel. Alcohol is the most commonly abused substance in the United States. Withdrawal is characterized by physiological symptoms that develop upon cessation of use. C. phencyclidine­ related disorders. There are frequent inconsisten­ cies in the patient’s story and symptom reporting.” Reliability: Poor. Alcohol Use Disorders Identification Test (AUDIT). psychotic disorder. There is often a lack of regard for how substance abuse affects family members and friends. amnestic disorder. Michigan Alcoholism Screening Test (MAST). and underlying comorbid psychiatric illness. blood alcohol level. Diagnosis: Axis I: Substance-related depend­ ence. Differential Diagnosis: Alcohol-related disorders. sexual dysfunction. Substance abusers are unable to fulfill work or personal obliga­ tions. mood disorder. Laboratory data: Complete blood count.related disorders. nicotine-related disor­ ders.Discussion I. and sleep disorder. Substance abuse is defined as substance dependence when tolerance and withdrawal symptoms develop. Alcohol-related disorders are thought to result from a multiplicity of factors. Tremors or “shakes. Diagnostic testing: CAGE Screening Question­ naire. Alcohol Abuse and Dependence . hypnotic-. amphetamine. The patient does not recognize the substance abuse as a problem and relates difficulties to environmental stressors or “depres­ sion. chemis­ try. caffeine-related disorders. B12 and folate level. intoxication. Tolerance occurs when the user requires increasing amounts of the substance in order to become intoxicated. cannabis-related disorders. Impulse control: When intoxicated. Clinical evaluation A. dementia. chest x-ray. Alcohol withdrawal delirium (delirium tremens) may present two to three days . The clinical features of substance abuse are a maladaptive pattern of use that leads to significant impairment. sedative-. delirium. and continue to use despite resultant inter­ personal problems. and auditory and tactile hallucinations (formication) may also occur within the first 48 hours of alcohol cessation. and cases of alcoholic demen­ tia may show scores less than 24. amy­ lase. triglycerides. withdrawal. opioid-related disorders. including biological predisposition. The initial signs of alcohol withdrawal are sweating and tachycardia. Insight: Limited. cocaine­ related disorders. they continue to use the substance in situations where it is physically dangerous. D. or anxiolytic-related disorders. II. lipase. cholesterol.

benzodiazepines. persistent failed ef­ forts to cut down. Substance abuse history: Substance intoxica­ tion can cause dissociative symptoms. Dissociative Amnesia is assessed by asking about episodic memory loss. or if he has ever found himself in places without knowing how he arrived. . Ask the patient if he has ever been told about out-of-character behavior. accumulating posses­ sions without remembering how they were ac­ quired. forgetfulness. or for personal infor­ mation. Other symptoms of substance dependence include taking larger amounts of a sub­ stance than intended. major depression. Patients are hydrated if necessary and thiamine is given to prevent the develop­ ment of Wernicke’s Encephalopathy. Patients with acute alcohol intoxication may require inpatient admission to prevent the development of seizures and delirium tremens. hallucinogens. blank spells. looking at oneself from overhead or at a distance. memory loss for specific intervals of time. hospitalizations. and other people taking control of the patient. being recognized by people the patient does not know. acute or post-traumatic stress disorder. A history of anxiety and depressive symptoms is a predisposing factor to developing a dissociative disorder. and perceived bodily changes like enlarged extremities. C. memory gaps. voices coming from inside. headaches. to treat dehydration. gradual onset of symptoms. marijuana. and associated distress. obsessive-compulsive disorder. Benzodiazepines are used for withdrawal prophylaxis and acute management of seizures. dizziness. and barbiturates. ask about memory loss for childhood events. Delirium typically occurs only in people who have abused alcohol heavily for many years. or being called by a different name.after cessation. Somatoform Disorders. If Dissociative Identity Disorder is suspected. Dissociative Fugue is assessed by asking about recent travel and identity confusion. blackouts. Long­ term inpatient rehabilitation and ongoing outpatient substance-abuse counseling are required to prevent relapse. therefore. Depersonalization Disorder is assessed by asking about feeling unreal. IV. E. Ask about comorbid symptoms of depression and anxiety. potential triggers. Dissociative symptoms can appear in schizophre­ nia. sudden vs. ask specifically about alcohol. Ask about losing time. B. ask about another person existing inside the patient. but patients are at risk for up to one week. see page 92.Treatment A. panic disorder. Inpatient admission is also considered when outpatient detoxification has failed. or to treat psychotic symptoms. date of onset. duration. Past psychiatric history: Past psychiatric diag­ noses. monitor suicidality. Also in dissociative identity disorder. and spending an enor­ mous amount of time trying to obtain the substance. Consider whether amnestic events are of a stressful or traumatic nature. and treatments. Dissociation . References. and histrionic personality disorder. borderline personality disorder. bipolar disorder. perceptual clouding. flash­ backs. being outside one’s body.History Taking History of present illness: Current symptoms.

rhythm. Family history: Psychiatric disorders in family members. such as derealization or depersonalization. Speech: Normal rate. and pregnancy test. Laboratory data: Complete blood count. cogni­ tion is intact. divorce. or they may be unaware of symptoms. Impulse control: Impaired during times of ex­ treme stress. Sensorium/cognition: Alert and oriented. Conversion Disorder. sexual abuse or other traumatic events.” Affect: Anxious. seizures. Patients are unaware of the relation of the symptoms to past experiences or their significance as a psychological defense mechanism. Perceptual: The patient typically denies auditory or visual hallucinations. including beta-blockers and anticholinergics. chemis­ try. dementia. but may experience dissociative symptoms. Reliability: Good. bipolar disorder. Doubling may also occur in which patients feel as though they are observing themselves from a distance. toxicology screen and blood alcohol level. Dissociative identity disorder may occur more frequently among first­ degree relatives. somatization disorder. and depersonalization disorder. The patient is able to describe symptoms in detail unless amnesia prevents awareness. major depression. Patients typically understand how behavior affects others and voluntarily seek treatment. schizophrenia. and volume. Past medical history: Neurological disorders. disso­ ciative fugue. Homicidality: Denies. substance intoxication or . history of physical abuse. exposure to domestic violence. dissociative identity disorder. Judgment: Fair.Social history: Family relationships. and the Dissociative Experience Scale. obsessive­ compulsive disorder. Mental Status Exam General appearance: Patients may appear in distress. Diagnostic testing: Electroencephalography. Thought process: Linear and goal-directed. posttraumatic stress disor­ der. relatives seeing a psychiatrist. clearly disturbed by the amnesia or dissociative experience. thyroid function tests. Hypothyroidism and hypoglycemia can also cause depersonalization symptoms. acute stress disorder. Medications: Medications. Reality testing is characteristically intact. Insight: Limited. Thought content: No delusional content elicited. or taking psychiatric medication. Mood: “Scared. head trauma. computed tomography. Suicidality: Suicidal ideation is possible during times of extreme stress. Diagnosis: Axis I: Dissociative amnesia. marital discord. Ask about legal history and possible motivations for secondary gain. and migraine headaches can all cause dissociative symptoms. dysphoric. including over-the­ counter and alternative treatments. Depersonal­ ization may be a side effect of several medica­ tions. brain tumors. General appearance can vary according to personality in dissociative identity disorder. Differential Diagnosis Psychiatric: Delirium. Perform a full mini-mental state exam in patients with amnesia to rule out demen­ tia.

patients have a sense of detachment from them­ selves. or generalized across a lifetime. emotional neglect. which mandates hospitalization. botulism.withdrawal (alcohol. head trauma. encephalitis. or in a dream-like state. B. Memory loss may be localized for a specific period of time. Neurological: Epilepsy. Psychotherapy may help patients to recog­ nize the impact of past traumatic events and . loss of a loved one. C.Discussion I. which protect against experiencing the pain of trauma. fatigue.Treatment A. barbiturates. Inpatient hospitalization is rarely neces­ sary unless symptoms of comorbid psychiat­ ric disorders are present and require admis­ sion. Epidemiology. Dissociative identity disorder was previ­ ously called multiple personality disorder. barbiturates. In dissociative fugue. Medical: Hypoglycemia. and medication toxicity or side effect. Risk factors include a history of trauma. such as divorce or financial hardship. fever. Clinical evaluation A. In depersonalization disorder. selective for certain events. although a non-pathological variant that is not distressful to the patient also exists. Benzodiazepines. borderline personality disorder. and the patient is aware of the memory loss. Depersonalization symptoms are experienced as abnormal and distressful. hypnosis. but may occur in the context of psychosocial stressors. hypothyroidism. Dissociative disorders may occur in people of any age. carbon monoxide poisoning. and cerebrovascular disease. Amnesia is the most common dissociative disorder. Unlike dissociative amnesia. and may describe feeling unreal. hallucinogens. II. D. C. patients in a fugue state do not recognize their memory loss or identity confusion. benzodiazepines. such as physical abuse. and histrionic personality disorder. Dissociative fugue is extremely rare. It is possible that alternate identities in dissociative identity disorder may exhibit impulsivity and suicidal or homicidal behav­ ior. IV. E. sexual abuse. B. patients wander away from home for hours to days and may assume another identity. and relaxation techniques may all be useful to facilitate recall in amnesia. or witnessing a death. Dissociative phenomena are consid­ ered immature psychological defense mecha­ nisms. brain tumor. It is characterized by two or more distinct identities that alternate in controlling the patient’s behavior. The history of present illness should focus on the nature of the symptoms and try to differentiate from among the dissociative disorders. marijuana). Patients with dissociative identity disorder may not recognize the existence of different identities within themselves.” and typically the patient does not recall time spent in alternate self­ states. Etiology. hyperventilation. Dissociative Disorders . migraine. Patients may also describe observing themselves from a distance. but are more common in young women. III. The patient may refer to himself as “we. Dissociative amnesia typically has an abrupt onset. sensory deprivation.

treatments. and menorrhagia. Substance abuse occurs more frequently in patients with somatization disorder and increases the risk of suicide. hospitalizations. difficulty swal­ lowing. and neurologi­ cal problems. diagnoses. blindness. history of physi­ cal or sexual abuse. anxiety. multiple sclerosis. duration. Social history: Living situation. diarrhea. sensory deficits.address the associated pain with improved coping strategies. loss of balance. eyes. hypnotics. and analgesics. and constipation. and somatization disorder occur more frequently in family members of patients with somatization disorder. Weakness. and volume. Mental Status Exam General appearance: Calm and cooperative. nose. Ask about pain. such as hair. marital conflict. and seizures. and mouth. and histrionic per­ sonality disorder are seen more frequently as comorbid illness in somatoform disorders. Past medical history: Ask about past medical illness. sedatives. erectile or ejaculatory dysfunction. polymyositis. but often ruminative about symptoms. double vision. systemic lupus erythematosus. Mood: “Scared. irregular menses. and Guillain-Barre syndrome can all cause symptoms that mimic somatization disorder and conversion disorder. Conversion disorder symptoms appear neurologi­ cal in origin and may consist of deficits in any sensory or motor system. Somatization disorder is as­ sessed by asking about pain. hallucinogens. anxiolytics. Dementia.History Taking History of present illness: Current symptoms. Speech: Normal rate. brain tumors. Family history: Substance abuse. Past psychiatric history: Ask about past hospi­ talizations. schizophrenia. References. nausea. such as loss of a loved one. rhythm. and suicide attempts. the patient may not exhibit an appropriate level of concern about symptoms.” Affect: Dysphoric or anxious. alternative. sexual dysfunction. a history of abuse. Decreased libido. depres­ sion. and all over­ the-counter medications. seizures. cluster B personality disorders. Somatization . income. Thought process: Linear and goal-directed. acute intermittent porphyria. vomiting. HIV. paralysis. and associated distress. low socioeconomic status. bloating.” “upset” or “depressed. and psychosocial stressors. gastroin­ testinal distress. level of education. heroin. and neuro­ logical symptoms. Body dysmorphic disorder is assessed by asking about preoccupation with an imagined bodily defect and perceived misshapen body parts. myasthenia gravis. psychosocial stressors. family relation­ ships. see page 92. Substance abuse history: Alcohol. A fear of having a medical illness suggests hypochondriasis. Previous conversion symptoms. skin. marijuana. and in the context of psychosocial stressors. Conversion symptoms are more likely to occur in patients with a low level of education. date of onset. surgeries. The patient may show inappropriate (incongruent) affect when describing potentially serious symptoms. . and divorce. cocaine. Medications: Medical.

Guillain-Barre syndrome. There is no evidence of poor impulse control. phobias. myasthenia gravis. Impulse control: Fair. AIDS. Clinical evaluation A. Laboratory examinations should be symptom-oriented to rule out specific differential diagnoses. but may exaggerate the severity. and mutism are the most common conver- .Discussion I. Insight: Limited. and electrocardiogram should be done as needed on a symptom-oriented basis. and schizophrenia may all present with somatic complaints consistent with somatoform disorders. and one neurological symp­ tom. B. The patient describes symptoms in detail. Sensorium/cognition: Alert and oriented. liver function tests. II. Homicidality: Denies. The etiology of somatoform disorders includes Freudian theories of repressed intrapsychic conflict. panic disorder. borderline personality disor­ der. and secondary gain where patients derive specific benefit from entering the sick role. Etiology. blindness. Specific complaints must include four pain symptoms. hypochondriasis. polymyositis. Reliability: Fair. Somatoform Disorders . but may have a history of suicide attempts. electroen­ cephalography. Epidemiology. conver­ sion disorder. one sexual symptom other than pain. urinalysis. chemis­ try. misinterpreted somato­ sensory input. Ideas of reference of people noticing the perceived defect may occur in body dysmorphic disorder. generalized anxiety disorder. Differential Diagnosis Psychiatric: Major depression. The patient is aware of effect behavior may have on others. There are also recent neuro­ imaging studies and other data to support biological and genetic roles in the development of somatoform disorders. Diagnostic testing: Physical and neurological exams. Paralysis. body dysmorphic disorder. systemic lupus erythematosus. but pain is the most common present­ ing complaint. multiple sclerosis. Somatization disorder is diagnosed by a history of multiple physical complaints be­ ginning before age 30. Somatoform disorders are characterized by physical symptoms that are not intention­ ally produced. The patient does not understand the psychological nature of symptoms. Diagnosis: Axis I: Somatization disorder. and periodic paralysis. two gas­ trointestinal symptoms. Judgment: Fair. Concern about symp­ toms and fear of illness do not reach delusional proportions in somatoform disorders. but have no medical cause. Medical/neurological: Brain tumors. Conversion disorder is characterized by motor and sensory symptoms that appear neurological in origin. intact memory and concentration. Laboratory data: Complete blood count. The prevalence of somatoform disorders varies according to the specific disorder. magnetic resonance imaging. C.Thought content: Illogical. III. Suicidality: Denies active suicidal ideation. histrionic personality disorder. Creutzfeldt-Jakob disease. Perceptual: Denies hallucinations or illusions. optic neuritis. pain disorder. and good fund of knowledge.

Hypochondriasis patients are convinced they have a particular disease despite all evidence to the contrary. Treat­ ment usually consists of cognitive-behav­ ioral or insight-oriented psychotherapy. and they are most common in patients who already suffer from a seizure disorder. Ideas of reference. Treatment A. Patients with body dysmorphic disorder may have a long history of plastic surgery. In pain disorder. rather than concern about the symptoms themselves. E. F. . Body dysmorphic disorder is character­ ized by a preoccupation with an imagined or exaggerated bodily defect. B. IV. Inpatient hospitalization for patients with somatoform disorders may be required for stabilization if functioning is severely im­ paired or suicidal ideation is present. and different body parts can be affected throughout the course of the disorder. and rituals to hide the defect may also develop. C. There may be an underly­ ing medical condition contributing to the pain. Pain disorder is sometimes treated with amitriptyline or gabapentin. D.” where patients do not appear appropriately con­ cerned about seemingly serious symptoms. The classic sign associated with conversion disorder is “la belle indifference. Pharmacotherapy is useful in treating comorbid anxiety and depressive disorders. compul­ sive checking of the defect. but psychological factors must also play a significant role. Pseudoseizures may also occur in conversion disorder. symptoms can affect any part of the body and must be severe enough to cause impairment in social and occupa­ tional functioning. Hypochondriasis can be distinguished from other somatoform disorders because patients are preoccupied with the fear of having an illness. G. such as a de­ formed nose. Routine physical and neurological exams are helpful for reassurance and to rule out the development of an underlying medical etiology. Body dysmor­ phic disorder may respond to serotonin reuptake inhibitors. Biofeedback training and relaxation techniques may also be helpful to reduce symptoms. D.sion symptoms.

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