A Short Course in Psychiatry

James Morrison, M. D. Professor of Clinical Psychiatry Oregon Health & Science University

January 2009

Contents

Preface Chapter 1 Chapter 2 Chapter 3 Chapter 4 Chapter 5 Chapter 6 Interviewing Psychiatric Patients Making a Psychiatric Diagnosis Depression Mania and Mood Swings Psychosis and Schizophrenia Anxiety and Panic

iii 1 29 33 54 69 90

Preface
Remembering my own years in training, I had originally thought to call this collection “The Impoverished Students’ Guide to Psychiatry.” Whatever you choose to call it, this copyrighted material is being provided free to OHSU students, residents, trainees and faculty. You may download it to your computer or PDA and print out portions for your personal use. I would prefer that it not be disseminated outside our academic community. For those who prefer an actual book (or an index—sorry about that, but time got away from me), I’d recommend Introductory Textbook of Psychiatry, by Nancy C. Andreasen and Donald W. Black. It has been the standard text used at OHSU for several years; copies are in our library. I want to acknowledge the faithful, close reading of this material by James Boehnlein, MD, whose many suggestions I deeply appreciate. However, any errors you’ll find are my own responsibility. This is a work in progress; I’d greatly appreciate it if you’d write to me about this material— what do you find useful, what’s confusing, how can we improve it for readers in years to come? James Morrison, M. D. Portland, Oregon January, 2009 morrjame@ohsu.edu

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“Why were you admitted to the hospital?” Some clinicians like to begin with small talk. That means. “What caused you to come for this evaluation?” works for outpatients. Try to sit across the corner of a desk or table from the patient—this gives you room to change the distance between you. show the patient where to sit. Much better to introduce yourself. or the weather.) Start off with a brief question that shows where you’d like to go. students bore the honorific title of Doctor. Getting Started When I was in training. so you don’t limited the scope of your information. Because the patient does most of the talking. as indicated by the patient’s need for space and comfort. Because it is both a science and an art. Also mention that you’ll probably take some notes. traffic jams. but everyone. including the patients. but psychiatric patients often feel too troubled to care much about ball games. Open-ended questions help you establish a working relationship with your patient: • • • • They give the patient the greatest possible latitude in coming up with a response. knew it was a fraud. a medical student. 1 . the inpatient equivalent is. they can’t be answered “yes” or “no” and you haven’t suggested a multiple-choice answer.” Ask if the patient is agreeable to the interview. and point out how long you expect it will take. what you read here will apply to nearly every patient you meet. the skill of interviewing will improve as you continue your training. Patients who are encouraged to talk freely tend to like the person doing the encouraging. During introductions. Note that the two questions I’ve quoted are open-ended. (Across the full width of a desk erects a barrier and hinders flexibility. they allow you to assess your patient’s thought and speech patterns. Although psychiatric patients differ in some ways from medical and surgical patients. They serve as bait when you are fishing for the sorts of problem you’ll need to explore.Chapter 1 Interviewing Psychiatric Patients The patient interview provides the gateway to the health of the patient. “I’m Pat Marshall.

you’ll sense that you’ve obtained a broad outline of what’s uppermost in your patient’s mind.Interviewing 2 Free speech Your open-ended invitation just to talk about the reasons for the evaluation should usher in a few moments of what I call free speech. you’ll gather details about each area your patient mentions. headache. delusions. reduced (or increased) activity level. obsessional thinking or compulsive behavior. Social or personality problems may be suggested by repeated marital conflicts. Most patients will respond with a few sentences. sweating. peculiar or bizarre behavior. Later on. and poor judgment. after asking. such as: “Tell me more about that” or “And then what?” Sometimes. Rapport Before we move on. or by job problems: being fired. changes in appetite or sleep patterns. and then you’ll have to prompt for more information with more open-ended invitations. just a nonverbal signal such as nodding your head or smiling can indicate that the patient is on the right track and you’d like to hear more. a history of severe emotional or physical trauma. blackouts. and repeated treatment failures. social withdrawal. fantasies or illogical ideas. abdominal pain. Then. financial or legal problems. panic. fluctuating affect. After moments to minutes of letting your patient talk freely. neurological complaints. Physical complaints can be signaled by increased or decreased appetite or weight. when your patient can rattle on about whatever comes to mind. legal difficulties. flat or inappropriate affect. convulsions. you should be looking for hints that your patient has a problem in one or more of these areas: Mood disorders (abnormally high or low mood) include such symptoms as affect that is depressed or flat (or too high and bubbly). a presentation that is overly dramatic or ingratiating (or grumpy). demoted. speech that is incoherent or hard to follow. Anxiety disorders can be indicated by complaints of nervousness. repeatedly tardy. loss of interest in usual activities. vomiting) and social consequences such as fights. health consequences of use (cirrhosis. “Are there any other important problems we haven’t mentioned?” move on to explore in depth the problem areas you’ve identified. During free speech. and death wishes or thoughts of suicide. feeling worthless. Psychosis may be suggested by delusions. let’s consider the relationship you’re trying to establish. hallucinations. hallucinations in any of the senses. excessive worry. bizarre behavior. trouble breathing. Rapport. weakness. Difficulty thinking (cognitive disorders) includes defects of memory. and impaired insight or judgment. trembling. and loss of friends. and pain that can occur in one or more of many locations throughout the body. is the second of two basic . the sense of mutual trust and understanding that helps people work together. unreasonable fears. marital problems. speech that is slowed or speeded up. and dizziness. physical complaints such as palpitations of the heart or irregular heartbeat. a history of sexual abuse. Each of these areas comprises a variety of disorders that have symptoms in common. bizarre or unpredictable behavior. Substance misuse includes indicators such as use of more alcohol than two drinks a day. Also watch for a medical or mental history that is vague or complicated. crying.

” “That’s about the best ‘serial sevens’ I’ve heard this week!” When you do offer praise for performance. you can offer praise when your patient does something especially well. I think we can move on to some other information. Maintain eye contact and nod your head to show that you are listening. you might avert your own negative feelings. For example: PATIENT: I don’t care about women. remember that the patient may find you hard to follow. (Here’s where your seating arrangements shines. it can not only poison your interview but imperil your chances at a solid future relationship. You might do better to express interest and compassion: “I’ve never experienced [that situation]. If angry or hostile (or euphoric). If you focus on the patient’s feelings.” “You must have felt miserable. your own feelings can heavily influence rapport.Interviewing 3 goals you hope to score during your initial interview (clinical information is the first). Of course.” “I can see that it upset you terribly. take steps to build good will: • Watch your patient’s demeanor. “I know how you feel…” but try not to. If it’s depressed. Follow up on material that is obviously important to the patient. You may be tempted to say. but don’t coast on this expectation. you’ll want to back off to give each of you more personal space. INTERVIEWER: Sounds like you’re awfully angry. Acknowledge that you have different accents and point out that either of you may have to ask for a repetition at times. when just thinking up the next question is an effort. Psychiatric patients are often keen at detecting BS. too. You can always return to the patient later for details that you overlooked the first time. your words can come across as hollow. so I can only imagine how horrible you feel.) Monitor your own demeanor. make sure that it is both accurate and heartfelt. you will naturally feel like moving a little closer for support. now. Most patients will expect to like you. and if you are insincere. Speak plainly (professional jargon can be really confusing) and with compassion. Unless you’ve suffered the loss of a loved one. That may seem hard to do early in training. • • • • • . You got a few hours? This patient then went on to talk about his overbearing mother and how each of his two wives had abandoned him. But if instead you strive for a relaxed conversation that won’t yield everything you want to know. been divorced. Patients who perceive that you like and respect them will return the favor. both of you may have a more productive experience. I’d like to see every one of them burn in hell. or experienced the countless disasters that patients bring.” If ethnicity or regional dialect makes it hard to understand your patient’s speech. Try to understand any objectionable behavior or attitudes in terms of the psychological problems you are evaluating. Have you had some bad experiences? PATIENT: Well. let me tell you. Almost anything will do: “You’ve really given me a good overview of your problem. rather than words or behavior. • On the positive side.

you don’t have to answer personal questions. but you may want to do so. for that matter. However. I didn’t grow up here. so I have a pretty good idea of what some of your experiences must have been. or any question. to avoid excessive familiarity. growing up in a ghetto. The latter style is more comfortable and it encourages patients to participate in treatment decisions. He later discovered that the patient had a severe personality disorder and hated the police. A recent study found that when older patients are addressed in what has come to be called “elderspeak”—“Sweetie. A resident confided to his new patient that he was a reserve peace officer. seldom more than once with a given patient. I’d probably thank the patient for . but I got most of my training here. is to counter with one of your own: “Why do you ask?” It plays for time and information that may help you decide whether to answer the question directly. Mr. especially during the initial interview. And I’d scrupulously avoid extending it to politics or religion—even offhand remarks have a way of getting around. The overarching principle is to focus on the patient’s interests and needs. If you attended the same high school. rather than loading all the responsibility onto the clinician. Mrs. instead. Ms.” “How are we today. but it can serve us all well: it is unseemly any ward personnel. less selfesteem and cooperation. With this caveat in mind. but especially students. She says no one else could really understand what it was like. use this technique sparingly.Interviewing 4 Boundaries The doctor–patient relationship has changed since I was a student. Actually. that coincidence might nudge you in the direction of rapport. sometimes you can encourage cooperation by identifying something that you and the patient share. It puts two minds to work. which can seem mocking and insincere. Many elderly people hate to be called “Young Lady” (or “Young Sir”). most of us prefer the less formal role of collaborators who explore issues with the patient.. and you never know when someone else will be put off by an opinion that your current patient applauds. not on your own. A question students hear has to do with age: “You seem so young for this kind of work— how old are you?” One way to handle personal questions. Then. I realize that this is not the universal practice among clinicians. which really isn’t any of the patient’s business. Patients who contribute to the management plan adhere better to treatment and complain less about bumps in the road to improvement. the doctor was often an authoritarian lawgiver who decided for the patient. it depends on the patient’s reason for asking— it may be simple curiosity or a desire to obtain reassurance about the clinician’s competence: PATIENT: Were you reared in this city? INTERVIEWER: What makes you ask? PATIENT: My mother told me to be sure to get a therapist who grew up here.” “Dear. now. and all. Jackson. even clinicians who encourage friendly collaboration must maintain boundaries. It’s generally safest not to reveal too much about yourself to your patients. I find I can maximize personal dignity and better maintain distance by using a patient’s title and last name—Miss. But I have the feeling you’ll be able to tell me a lot more. I’ve lived in town for nearly 8 years. INTERVIEWER: I see. The first step in maintaining boundaries is to know where they are. Hon?”—they respond with greater depression and dependence. to address patients by their first names or infantilizing terms. Yet.. Of course. (I wouldn’t give a direct answer about age.

(Barely) verbal encouragements. direct request. You must avoid false generalizations based on insufficient knowledge. just a syllable or two—“Yes” or “Mmhmm”—can indicate that you understand and that the patient should just keep talking. briefly summarize what’s been said. and how about your drinking? From time to time. reassurance must be sincere. PATIENT: …and during the last few weeks. in your place. your words will seem hollow and reduce your credibility. “So. What did you have in mind?” Just re-request the information. which was…” 5 Managing the Early Part of Your Interview During the early part of your interview. he was a heavy drinker! INTERVIEWER: Yes.” Repeat your patient’s own last word to request more in the same line of thought. To be truly supportive. it can seem forced or false. Dad died. when you lost your job. your wife left.” (Many patients will grumble that. factual. “People tell me I look young for my age” or. my dad. I can see why you are valued in your company. But let’s get back to my question. I’ve got so much living to do… • • Reach back to a phrase or idea that wasn’t the patient’s last-spoken thought: “Earlier. Perhaps the most straightforward encouragement is a simple. Sometimes.” . such as “Please explain what you mean” or “Tell me more about that. either. but only offer it when it’s deserved: “I think you handled your boss with tact and sensitivity. and specific to the situation. nearly invisible methods: they maintain nearly continuous eye contact. but mostly. You can reassure with praise. such as “I wouldn’t worry about that” or “I’m sure it will all work out just fine. you want to keep your patient talking with as little intrusion as possible. you were doing pretty well until 8 or 10 months ago. INTERVIEWER: Death? PATIENT: Well. and then you started drinking. I’ve thought a lot about death.Interviewing the compliment and with a big smile say something like. and lean in a little closer to show interest. as I understand it.) And because you obviously can’t peer into the future. you said that you’d thought a lot about death. Several non-directive techniques (they urge further speech without dictating its content) can facilitate this goal: • Nonverbal encouragements. smile or nod for appropriate responses. we reassure by what we say. If used too often. they wouldn’t worry. INTERVIEWER: Can you tell me about your drinking? PATIENT: Now. Experienced interviewers instinctively use several subtle. “My actual age might surprise you. it also promotes rapport. just to make sure you and your patient are on the same page. Is that right?” • • • Offering reassurance Reassurance is whatever you do to increase your patient’s confidence or sense of well-being. and I felt so frightened. Smiles and nods are fine.

libido may increase. location (inside the patient’s head. . Try to encourage precision: “Had you started to feel depressed by your birthday this year? By Christmas?” If this approach draws a blank. interval. the direction will be down. Is constant fatigue a change? Has it interfered with normal activities? Daily mood variation. for mania. Appetite and weight. Some depressed patients feel worse upon arising but improve throughout the day. in which patients awaken during the night (especially found in heavy drinkers and those who have PTSD). an ancient term that refers to body functions involved with preserving health and vigor. Learn as much as possible about your patient’s symptoms. and intensity (distant whispers to loud screams). Classically. but they increase even in some patients with mood disorder. its symptoms. appetite and weight decrease with severe depression.Interviewing 6 Gathering the Database History of the present illness Once you’ve identified some of the major problem areas you need to explore. you need to watch for hints of new territory that you also will need to cover. All the while. ability. symptoms begin gradually or the patient is vague about onset. Energy level. Interest in sex is often an early casualty of mental disorder. Learn where in the sleep period it typically occurs—terminal (or late. Are they constant or do they come and go? If episodic. are common. How people feel can vary with time of day. Some patients sleep too much when they are ill (especially true of depression in younger people). how often do they occur and with what intensity? Has the intensity or frequency changed recently? Are the symptoms associated with any factor such as time of day or type of activity? For example. For most mental disorders. early (experienced from time to time by normal adults who have problems of living). outside the room). others experience the opposite pattern. and enjoyment of sex have changed. Onset and sequence of symptoms Your patient may be able to tell you exactly when the symptoms began: “I started to feel depressed when my wife said she was leaving. try to judge by how closely clothing seems to fit. consequences. Was weight change intentional? If your patient hasn’t weighed recently.” More usually. you can characterize auditory hallucinations as to their content (noises. so explore whether your patient’s frequency. Sexual interest and performance. isolated words. usually associated with severe depression or melancholia). complete sentences). start exploring! This means learning all you can about the current episode of illness—how it began. Many patients complain of insomnia. the depression or the renewal of your drinking?” The answer could help determine the type of treatment you eventually recommend. Vegetative symptoms Vegetative symptoms. and possible stressors. mumbled speech. explore the sequence in which your patient’s problems began: “Which started first. always look for evidence of change from prior functioning in: Sleep. in the air. you might ask. “When did you last felt well?” If even this fails.

” . shifting gaze. or worsened your patient’s mental problems. Previous episodes You’ll need to learn details of prior episodes: When did they occur? What were the symptoms? The diagnosis? What were the social consequences? If hospitalized. precipitated. even separation or divorce? Interpersonal. a patient claimed his depression started when he discovered fleas on his dog. (Beware a “no” answer attended by hesitation. You can gently approach the issue: “Have you ever had desperate thoughts. or been fired as a result of illness? Disability compensation. but you’ll often identify an event that may have caused. but anyone with a potential for self-harm will have already considered it. and effects (both wanted and unwanted). but I feel I must. the real risk is in asking too late. quit a job. From a vast range. learn how well the patient cooperated with treatment. at home. in fear of job loss. or private insurance. Some beginning interviewers worry that they’ll suggest suicide to a patient. Personal interests. such as wanting to be dead?” Pursue positive replies with questions about thoughts of self-harm. Has there been serious discord. Seriously ill patients typically lose interest in sex. Ask: “Have you ever had any police or legal difficulties?” Follow up positive answers with “Have you ever been arrested? How many times?” “Have you been in jail? For a total of how long?” And of course. with spouse or friends. so ask: “Have you ever had trouble following your doctor’s advice?” “What sort of difficulty have you had?” Suicide and other violent behaviors Every patient requires an evaluation of suicide potential. or tears—each suggests that the answer may be less than candid. sometimes (as with antisocial personality and substance use disorders) it can even determine the diagnosis. you must judge which alleged stressors are valid. I hate to pursue this subject. hobbies. TV. “You seem so uncomfortable. “What were the charges?” Employment. besides such basic information as name. Sometimes it’s obvious—acute intoxication or a suicide attempt—but an outpatient may have come in at the behest of concerned relatives. Try to learn why your patient appears for evaluation now. (For example. been shunned by relatives? Legal. Department of Veterans Affairs. ask: “Was something going on that might have started your symptoms?” Possibilities include issues at work. illnesses. and anniversary reactions. Chronic illness may trigger benefits from the Social Security Administration. or out of concern about worsening symptoms. frequency. dose. You’ll therefore want to learn what the effect of symptoms has been in these areas: Marital and love relationships. Has your patient missed work. plans. reading. legal problems. duration of use.) If you haven’t heard about any possible stressors. state compensation board. Has the patient avoided or fought with friends. People often resist admitting to poor compliance.) You could comment. how many times and for how long? What treatments were tried? Which worked best? Was recovery complete? For how long? Was there a period of time that the patient remained well without prophylactic treatment? For previous medications.Interviewing Stressors 7 Some disorders seem to begin spontaneously. and past suicide attempts. Consequences of illness The effect of mental disorder on human interactions can help you judge its severity.

“I’m glad I didn’t succeed. or been concerned about controlling impulses. At another time. how many drinks do you have?” I worry about anyone who consumes more than 60 drinks per month. thereby reducing the patient’s impulse to conceal it. which we used to call alcoholism. Explore any risk of violence. you’ll need to ask whether the patient has ever been involved in fights. is defined by its consequences. trust me. Avoiding suicide and other harm is a duty of clinicians. A physically serious attempt is one that could result in significant bodily harm. 3. So: 1. perhaps when someone else was with the patient. The room should have an alarm or someone should be within earshot of a call for help. For alcohol or drug use. but so is maintaining confidences. At the other extreme are attempts that suggest the patient had something in mind other than dying—“gestures” such as a lightly scratched wrist or swallowing 4 or 5 aspirin. or inflicting a gunshot wound to the abdomen. then do so. you’ll explore the legal aspects of medicine in Oregon. words (threats or insults). but isn’t. 4. and body language (agitation. a 6-ounce glass of wine and a 1-ounce shot of 80-proof hard liquor. severing an artery or large vein.” That could mean.” Respond to suicide behavior that is either physically or psychologically serious with speed and vigor. such as swallowing a potentially lethal drug dose.) Don’t be put off by someone who says. 6. on how many days do you have at least one drink of alcohol?” Then ask “On a typical drinking day. A psychologically serious attempt is one where death seems clearly intended—the patient took pains to avoid discovery or greets survival with regret: “I’m sorry it didn’t work” or “I’ll try again. get help at once. inducing a deep coma. or put yourself closer to the door than is the patient). 2. Provide an unobstructed exit from your interview room (two doors. Be especially wary of any patient who has a history of violence or who should be taking antipsychotic medication. harmed others. (The following drinks have roughly the same alcohol content: a 12-ounce beer. announce that you are leaving the room (the announcement is to avoid startling the patient). To normalize drinking of alcohol. Otherwise. 5. “I haven’t had a drink since Saturday night. even in teens and senior citizens. All health care personnel must ensure their own personal safety when talking with patients—being the target of a threat or assault is worse than no fun. If you perceive any danger to or from your patient. Substance misuse Substance misuse is so common (about 8% of adult Americans. immediately notify your supervisor.” Psychologically less serious attempts are those that are made impulsively. assume that everyone drinks some and ask: “In an average month. If you sense danger.” Although the amount a person drinks is an important indicator. you’ll need to explore the following areas: . You must assess both the physical and psychological seriousness of any previous attempt. Watch for indicators of potential violence in the patient’s voice (rising tempo or pitch). 25% of adults with psychiatric illness) that you must always consider it. alcohol dependence. clenched fists). “I don’t touch alcohol. or when the patient admits.Interviewing 8 Facts about past suicide attempts help predict further attempts. A history of domestic quarrels or legal difficulties can ease you in to this line of questioning. Then.

I start to feel nervous. being clean]?” “How did you achieve it?” 9 Getting the Facts About the Present Illness An accurate diagnosis requires all the relevant information. I won’t get the wrong idea about you. just say. divorce. Loss of friends. “I understand that you hesitate to confide in me. They include accurate details about these aspects of your patient’s symptoms: Type Duration Severity Context in which they occur Frequency This exploration will require the use both of closed-ended and open-ended questions: INTERVIEWER: When did you first notice these episodes of anxiety? [Closed-ended] PATIENT: It must have been about 2 months ago—I had just started my new job. but for a full. drugs]?” “What happened as a result of treatment?” “What’s your longest period of [sobriety. setting rules about when to drink. INTERVIEWER: Please describe an episode for me? [Open-ended] PATIENT: For no reason. certain items of information are always necessary. Then I can’t breathe. being unable to stop after the first drink Medical.’ and we’ll move on. rich exploration of any behavior or event.) Instead of “How often have you been hospitalized?” say. vomiting spells. .” (You might learn about drinking episodes or suicide attempts. don’t realize that misinformation can have serious consequences. Absenteeism. drunk driving. INTERVIEWER: How often have these attacks occurred? [Closed-ended] PATIENT: I’m not sure—it’s been getting more frequent. “Please tell me about your other hospitalizations. (Some patients.Interviewing Loss of control. blackouts (amnesia for events while drinking) Legal.) Instead of “Did your appetite change?” ask. Drinking more than the patient intends. drug use]?” “Were you ever treated for the use of [alcohol.) Each symptom has its unique set of details that must be explored. fighting. Studies show that open-ended questions are more likely to yield valid information. It’s awfully scary. Spending money on drink/drugs that should have gone to food or family support Job. guilt feelings Financial. “How was your sleep then?” (Some depressed patients sleep too much. so continue to use them when you can. Sometimes you must explicitly state that you need the truth. gulping drinks. Instead of “Did you have insomnia with your depression?” try. especially teenagers. Let’s play it this way: If you feel you can’t tell me the truth. accidents Interpersonal. “To what extent did your appetite change?” (“To what extent” can change nearly any closed-ended question into an open-ended one. Arrests. being fired Follow up positive responses with: “Have you ever been concerned about your [drinking. For example. Liver trouble.) That’s why I might say. ‘Let’s skip that for now. That way.

I suppose. use a gentle. “Help me understand: You just said that your father threw you out of the house. In 15 minutes or so. and so should you. you should play the confrontation card sparingly. when you don’t really know the patient well. Long questions with involved explanatory detail can confuse the patient. “You haven’t been drinking heavily.” The I thought draws the sting of any implied criticism by suggesting that you might be the one who is mistaken. no. Too. other terms may not be. Encourage precision. • • • • • Confrontations Confrontation doesn’t imply angry. INTERVIEWER: What sort of help have you sought before? [Open-ended] A few rules For the sake of completeness. But when the stakes are high—let’s say your diagnosis turns on this fact—you must clear up the confusion with a confrontation. judges on TV crime shows overrule them. What else is there to this story?” Of course. ask for dates. times. perhaps a historical inconsistency or a contradiction between the story and how your patient seems to feel. leading questions hint at the answer expected. it starts to go away. so you might have to use your patient’s street terms for sexual acts and body functions. I felt sad—but you are smiling. but double questions are often confusing. I’ll mention a few other obvious rules of interviewing: • Use language the patient understands.Interviewing INTERVIEWER: Several times a day. Instead of “Has drinking ever caused serious problems. “Heck. Like negative questions. the patient may respond to one part of the question and ignore the other. “Sleeping with” for “having sex” is commonplace. such as missing work?” ask “Have you ever missed work because of drinking?” Avoid double questions. but earlier I thought you said he died years ago. try to avoid even “friendly” confrontations in an initial interview. and numbers.” Avoid leading questions. have you?” essentially demands the answer. multiple-choice] PATIENT: About once or twice a day now. INTERVIEWER: What do you do about it? [Open-ended] 10 PATIENT: I’m too shaky to stand. during an interview session. so I just sit down. without your realizing it. they also occupy time you could be using to listen to the patient. once a week? [Closed-ended. Keep questions brief. Here’s another way to soften the question: “When you told me what happened to your wife. Don’t phrase questions in the negative—it telegraphs the expected answer. Where appropriate. supportive manner. (“Have you had trouble with your sleep or appetite?”) They may seem efficient. Then. . It means that something needs clarification. However.

but resist exposing their vulnerabilities. For example. “About those episodes of intense anxiety—can you tell me some more about them?” Then. for very anxious or depressed people. others may understand very well how they feel. you state the emotions you think the patient might feel in a particular situation. some find it hard to talk about feelings—perhaps their relatives hid their emotions or their culture discouraged behavior that isn’t “macho. probe for more details. A person who talks at greater length is more likely to reveal true emotions.” Picking up on emotional cues. For a patient who cannot identify feelings. keep probing until you have all the facts.” Some just don’t recognize their own feelings or have difficulty connecting them to their experiences (a condition called alexithymia). These techniques can help cap excessive verbal and behavioral output: . “Your boss gave his nephew the promotion you thought you had coming? You must have been livid! And depressed. as with people who don’t understand the cause of their own feelings. When using a direct request. “Anyone who’s had your problem would feel hurt [or angry or sad]. For example. “When you mentioned your daughter just now. This means. and we could get along on less money. My boss has put me under an awful lot of stress. Here are some other techniques for eliciting emotions: • • Express sympathy or concern. “Did you feel that way when your father died?” And always. be sure to mention feelings or emotions specifically. “What do you think…?” you might obtain only cognitive material. if you ask. • • • Handling the excessively emotional patient Emotions sometimes interfere with communication. and for those who control others through intimidation. PATIENT: I’ve had a really tough time at work.” Reflection of feelings. for those who were reared in families where intense expression of emotion was the custom. I thought you looked a bit down. And I could try writing the novel I’ve dreamed about… Although most patients will give you information about any emotional state you are interested in. using techniques we’ve already discussed: direct requests and open-ended questions.Interviewing 11 Interviewing about feelings Studies show that beginning interviewers often neglect to ask about feelings—a serious omission in a mental health interview. What were you feeling?” Analogy. You provide a verbal expression of the slight (often nonverbal) cues to emotional states. I could spend more time with the kids. Instead: “How did learning about your husband’s affair make you feel?” or “What was your state of mind when you found out you’d been demoted at work?” Open-ended questions allow the scope to sort out possibly ambivalent feelings. what with downsizing. At times I’ve felt that I can’t even do my job… INTERVIEWER: (Nods without speaking) PATIENT: But my husband points out. try to evoke the context of a previous experience. INTERVIEWER: You said you’d considered leaving your job—tell me more about that. Eliciting quality information about feelings is usually pretty easy— just ask.

which may allow the patient to turn down the heat. unable to remember how he got there. “I’ll use this time to study hard and complete my education.] Fantasy.] Splitting.” Effective defense mechanisms Altruism. it’s ‘better to have loved and lost than never to have loved at all.” Humor. “She still loves me. divided into groups according to whether they are generally considered to be effective or harmful. earn a potful of money. she said I was a rat.’” Projection. She wouldn’t even let me— INTERVIEWER (interrupting): Did you and she have any kids? PATIENT: Two. Right now. “She’s actually pretty dumb. Potentially harmful defense mechanisms Acting out. “I’ll put this on the back burner. “Women can be wonderful or horrible.” Anticipation: “Next time.” Reaction formation. I can’t imagine what I ever saw in her. INTERVIEWER: Can you tell me about your previous marriage? PATIENT: It was god-awful! That bitch should rot in hell. [The student keys the car door of his rival. “I still love her. “I’ll write a book. it’s her mother who turned her against me.] “She hates me. and perhaps later we can discuss that some more. she’s one of the bad ones. Speak quietly yourself. Defense mechanisms We use defense mechanisms to cope with our feelings. “You really feel angry about this. and they’re just as bad as their mom. lower the volume of your own voice. [The student “forgets” to return the girlfriend’s CD collection. Always emailing and texting for— INTERVIEWER: How long were you married? This patient soon learned to stick to the subject. we’ll illustrate by a college student upset at being dumped by his girlfriend.] “I wouldn’t have been able to take her out. I need to learn about your current relationship. Just saying.” Devaluation. anyway.” .] Denial.” Switch to close-ended questions. Rather than merely stating a definition. but I want most for her to be happy. [Unconscious thought: I hate her.” Intellectualization.” Repression. below are a number of the more common ones.” Suppression.” Somatization. If your patient shouts. and she’ll beg me to take her back.Interviewing • • • • 12 Label the emotion. [The student goes home and starts a fight with his roommate. [The student awakens in the morning in a strange room.” Displacement. [The student thinks: “What a bitch!”] “I admire her for her principles. Angry and frustrated!” conveys your understanding.” Sublimation. “I know your ex-wife infuriates you.] Dissociation. Most people find it hard to yell at someone whom they must strain to hear. “I called her an angel. Re-explain what you want. Maybe we were both wrong. “I agree with Tennyson. Many of these instinctive techniques have been identified. [The student develops chest pains. I’ve got other fish to fry. I’ll plan better to protect my feelings.

dissociation. what was the source of support then? Frequent job changes are typical of antisocial personality disorder. and rank at discharge. you’ll need detailed information to evaluate the possibility of posttraumatic stress disorder. ask about military service: dates. Support issues can help assess your patient’s chances for response to treatment. tics? How were they addressed. You can ease into the subject of abuse by asking. Nowadays when we enquire about marital state. stuttering.Interviewing 13 Personal and Social History As important as social history can be for diagnosis and ongoing care. nightmares or night terrors. parents’ occupations) you’ll want a general picture of your patient’s early life. check the validity of items that seem questionable. Many adults will have sketchy memories of their childhood health. regardless of legal status. Have there been periods of unemployment? If so. phobias. source of the abuse and parents’ reactions to it. Are they pursued alone or with others? How religious is your patient? Has this changed from childhood? Also try to learn something of your patient’s social support network—the number and quality of relationships with family and friends. sex information must be actively pursued in a psychiatric interview. Still relatively taboo in everyday conversation. you should always maintain a healthy skepticism as to its accuracy: memories fade. but you might ask about overall health status: Generally healthy? Frequent trips to the doctor? Long absences from school? Parental “rewarding” of illness behavior with attention can precede some somatoform disorders. disciplinary problems. For women and men. If the patient saw combat. and what effect did they have on relationships with schoolmates or siblings? When did dating begin? Did any sexual issues begin about this time? Be alert for indications of sexual or physical abuse. and recall can be selective. Does your patient now live alone or with someone? In an apartment or house? Has your patient ever been homeless? What is the current financial situation? You can ask. duration. they can mold personality and have a lasting effect on adult relationships. “Did you ever feel mistreated as a child?” and then request follow-up information. such as type. number of siblings and birth order. and personality disorders. PTSD. A significant minority of psychiatric patients have suffered childhood sexual or physical abuse. Were there any of the common childhood problems: bed-wetting. and its effects can persist into adult life. job satisfaction). Childhood and adolescence Ask. “Has money been a problem for you?” Ask about leisure activities. “Tell me about . Was this a wanted child in a close-knit nuclear family? Were there any losses from death or divorce? Did your patient have friends and enjoy hobbies and other interests outside of school? Whereas most of these issues are unlikely to make or break a psychiatric diagnosis. frequency. we implicitly include relationships with partners of either gender. How far in school did the patient progress? Were there scholastic or disciplinary problems? Difficulties concentrating or sitting still in the classroom? Childhood hyperactivity with attention deficit is common. Adult life You’ll want to know about work history (number and type of jobs. which can stand as a precursor to somatization disorder. You could start by asking. obesity. “Tell me about your childhood. Whenever possible. among others. prolonged unemployment can be found in severe mood disorders and in schizophrenia.” Beyond the bare facts (birthplace.

Has the patient ever been arrested? When. elaborate with.”) If this yields a blank stare. because you will occasionally encounter a patient whose depression was caused by Lyme disease or a psychosis that was the result of an endocrine disorder. and concerns about possible homosexuality or bisexuality. sexual orientation as an adult and level of comfort with that orientation. Some other possible questions: “What sort of situations do people think you have trouble handling?” “How well do you control your temper?” “Is there anyone—any type of person—you can’t stand?” Of course. “What do you mean?” you can say: “I’m trying to find out how your sexual functioning is usually. which are usually familial and frequently hereditary. If your patient is in a committed relationship. it is especially important to learn about general medical symptoms and previous diagnoses.” Assess strong and weak points in this relationship.” You’ll also want to learn something about early sexual experiences (age and nature. a chronic illness that affects perhaps 8% of female psychiatric patients (rarely. as well as information about past marriages and divorces. dyspareunia. Ask about relationships with others and examples of how the person typically copes with stressful situations. I usually start with a rather long speech like this one: . and highly pertinent to many psychiatric disorders. Family history Here.Interviewing 14 your partner. you’ll need to be explicit. is any family history of psychiatric illness. “What do you like best [like least] about yourself?” This fishing expedition could net information that will help you assess self-esteem and characteristics that may have smoothed (or hindered) your patient’s path through life. How long has the couple been together? What are their relative ages? What have the problems been? How have the patient’s current mental problems affected the relationship. anxiety. as well as those of previous ones. any extended family. so you’ll have to ask. infidelity. Legal history can tip you off to personality disorder (especially antisocial) as well as bipolar disorder and substance use issues. “Could you tell me about your sexual functioning?” is a good way to start. patient’s reaction to them). premature (or delayed) ejaculation. in men). when you know the patient better. rather two people with mutual problems of living. Side effects of medications can also produce a variety of mood. you might forget. and even psychotic disorders. and vice-versa? For many patients. Ask for a self-appraisal of the patient’s own personality (“Describe yourself for me. and what were the circumstances? What was the resolution? For obvious reasons. To ensure that your patient understands what you’re after. Better to bite the bullet and start right in. you would pursue the general medical history anyway—that’s what doctors do. people may paint too rosy [or gloomy] a personal assessment of personality. and how it’s been affected by [the presenting problem]. You’ll also need to know about children from this relationship. Medical History To be sure. there is no definable mental disorder. especially during childhood. Consult standard texts for the specialized review of systems used to evaluate somatization disorder. siblings. Don’t forget about legal difficulties. you hope to learn biographical information about the patient’s relationship with parents. Although you can put off asking about sex to a subsequent interview. A fuller picture requires information from significant others and previous clinicians. be alert for some of the problems that typically affect couples: impotence. children and. But in psychiatry. STDs. If the response is. but your rough assessment could highlight some of the issues that you need to consider in treating this patient. people seldom raise these issues spontaneously. In addition.

brothers and sisters. children.” Nod or smile approval when you get the sort of brief answer you’d like. nieces. delinquency. and ask you about…” . what if your patient is still talking about Grandpa Jim? You’ll need to encourage brevity without impairing rapport. INTERVIEWER: And did you have any military service yourself? If you do have to make an abrupt transition. aunts. such as at work?” For a patient who continues to ramble. They’re still important for information about emotions and. uncles. so you can make your own evaluation (his psychosis could have been due to bipolar disorder or alcohol dependence). nervous breakdown. suicide or suicide attempts. if there’s time. cousins. hypochondriasis (define this term if you think the patient won’t understand). or arrests or incarcerations? Any relatives who were considered odd or eccentric or who had difficult personalities?” Move slowly enough through the disorders to give your patient time to consider. And don’t accept a diagnosis of schizophrenia. just because that’s what family mythology has passed along as the reason for Grandpa Jim’s mental hospitalizations. depression. flag it so the patient realizes you’re intentionally changing direction: “I’d like to change gears. By ‘blood relatives’ I mean your parents. relationship—can smooth the flow of a conversation: PATIENT: …it was the last time I saw my brother before he enlisted in the Army. now. Have there been other problems. you may need a firm intervention: “Our time is a little short…” “Let’s stick with the main topic for now…” By this time. You can incorporate your patient’s own idea or words: PATIENT: …my wife’s relationship with my son really improved after he got a job. psychosis or schizophrenia. too? Any common factor—place. so try to make your interview seem more like a conversation with smooth transitions between topics. Anything this serious demands that you fish around for information about symptoms and response to treatment. then. Control of the Later Interview At this point in the interview. Make an empathic comment before changing subjects: “Your relationship with your husband sounds distressing. time. INTERVIEWER: And what about your own relationship with her? Did that improve. grandparents. you’ll be using more closed-ended questions—those that can be answered “Yes” or “No” or with a specific piece of information such as a date or name—but don’t completely abandon open-ended questions. and nephews. mental hospitalization. you want succinct answers to specific questions. Has any of these people ever had nervousness. Transitions Interrogations are no fun. problems from drug or alcohol dependence. let’s focus on…” or “Let me interrupt here to pursue something else that’s important. to give you a breather. because they require less work. Now.Interviewing 15 “I’d like to know whether any of your blood relatives ever had a nervous or mental disorder. • • • • • State your need to move on: “I’d like to hear about that later.

protecting another person. forgetfulness (“I don’t know” about something the patient should remember very well). It’s hard. swallowing). Switch the discussion from facts to an exploration of feelings. “Just tell me what you’d be comfortable saying about [this issue]. try to obtain a nonverbal response first—just a nod of the head will do. 16 With “I realize your husband’s death makes it hard to talk about him. and it’s normal. Express sympathy. “Have you ever had the opportunity to apologize for your behavior when you were drinking?” Here. • Resistance Most of your interviews will be models of cooperation between you and your patient.” you acknowledge your patient’s distress but declare that the topic is important to pursue. yawning. anyway. involuntary behaviors (flushing. contradictions to what was said earlier. • • . but I do need to understand all about you. but didn’t. changing the subject).” Name the emotion you think your patient might be experiencing. you soften the question by suggesting that chance might have prevented some praiseworthy action the patient should have taken. “How would you feel if the police picked you up for drug use?” Supposition helps your patient achieve some distance from an emotionally charged situation.” This last statement also underscores the medical need for a complete database.Interviewing Demonstrate concern for the patient’s feelings. Remember that the issue isn’t you. • Try refocusing the question in slightly altered form: INTERVIEWER: Have you had any ideas you might kill yourself? PATIENT: (several seconds of silence) INTERVIEWER: I was wondering whether you’d had the desire to die? • • • Give the patient a degree of control with something like. especially with highly charged questions. voluntary behaviors (poor eye contact. omissions in the story. uneasy shifts of posture. • • • • A sympathetic facial expression or tone of voice can soften any question. it’s the patient. with the reassurance that such feelings are normal. You’ll recognize resistance by one or more of these features: being late to an interview. “How do you think other people would cope with a child who’s had drug problems?” By asking how others would react or feel in a similar circumstance. Several techniques can help move the interview around such an impasse: • Don’t be drawn into the patient’s anger or other agenda issues. “I know it’s hard to deal with some of this material. For a silent patient. Any of these behaviors may be out of anger or lack of trust. or in the service of avoiding embarrassment or criticism. But some patients may resist giving up certain details of information. silence. you can reduce your patient’s sense of isolation and responsibility.

In waxy flexibility. with pressure. General appearance and behavior Besides ethnicity. for the balance. and apparent age. About half of it you obtain by simply observing while you interview. but it could suggest a drug overdose.” Exaggerate negative consequences that didn’t happen: “Nobody died. and catalepsy usually indicate psychosis. you want your patient to develop the habit of responding to your requests. Facial expression may be “normally mobile” if your patient smiles. reduced. Mostly. Mannerisms are common and usually normal. posturing. Stereotypies are non-goaldirected behaviors such as crossing oneself without apparent purpose. again without apparent purpose. a misbuttoned shirt could mean dementia). Although depressed people are often underactive. These are often better reserved for use by more experienced interviewers. you’ll want to notice nutritional status (does this patient look anorectic?) and hygiene and clothing (bizarre dress suggests psychosis. the limbs are rigid but you can slowly. waxy flexibility. Carefully note any other involuntary movements. bend an elbow as if it were a soft wax rod. gender.) A fluctuating level of consciousness could mean delirium. you’ll have to ask questions. more often anxiety) or clenched fists. uneasy shifting of position or jiggling a leg while seated is usually simple anxiety. “All that stress probably made you want to drink. Watch for tremor (possibly parkinsonism. even after you have said. such as picking at skin or clothing (found in delirium). and otherwise responds appropriately throughout your conversation. the gestures you notice will be everyday “talking with the hands.” though some will express unvoiced ideas—the circled thumb and finger OK and the not-so-OK extended middle finger. they are infrequently encountered today.Interviewing • Only as a last resort should you delay the discussion. How alert is the patient? (Drowsiness may be simply due to fatigue. “You can relax. now. Motor activity could be normal. A patient with catalepsy holds an odd or unusual posture that you physically impose. A patient who repeatedly glances around . a side effect of the older antipsychotic drugs. Note any mannerisms—the unnecessary behaviors that are a part of a goal-directed activity. And watch for hyperalertness (excessively vigilant scanning of the environment (found in posttraumatic stress disorder and paranoid disorders). you can pull information from a reluctant patient by using somewhat riskier techniques. A person who postures will strike and hold a pose (think Napoleon). frowns.” Stereotypies. a classical feature of schizophrenia but also found in profound depression or frontal lobe dysfunction due to various medical conditions. but an occasional. 17 Sometimes. Overactivity could be the pacing or fidgeting of akathisia. • • • Offering an excuse for information that could be seen as unfavorable. or excessive. but weren’t?” Mental Status Exam—Observational Aspects Your evaluation of current mental functioning is the mental status exam. did they?” Induce the patient to brag: “Has there been any behavior for which you could have been arrested. true immobility is pretty rare. A patient who deliberately turns away from you may be showing negativism. negativism. such as the flourish some people make before signing their names. It is found in catatonia.

or is it dull and monotonous? What can you deduce about education or family background from use of grammar? Accent often identifies the country or region in which the person was reared. many regard mood as meaning the way someone feels and affect as how that person appears to feel. as if listening to voices or noticing something you cannot see may be experiencing a psychosis. flushed face or neck. Are there tics of eyes. Notice your patient’s eye contact: gaze riveted to the floor may be due to depression. perhaps going from ecstasy to tears and back within moments. We use several dimensions to describe mood (affect): Type When you ask.Interviewing 18 the room. contempt. mouth. and in Parkinson’s disease and other neurological illnesses. try to learn whether this mood differs from the grief a person feels at the loss of a loved one. Is the tone of voice friendly. blushing. shrugging In evaluating depression. It is found in severe depression. sad. and tearfulness. as you should. and surprise. You can also infer much from body language: Anger: clenched jaw or fists. By the latter definition.” Others may admit to one of these basic emotions: Anger. However. which we’ll use here. or other body parts? Does your patient’s voice have a normal lilt (called prosody). This could be a brief (seconds) depression sometimes encountered in mania or the affective incontinence sometimes noted in dementia. extended neck veins Anxiety: jiggling foot. Does the patient lisp. Then we identify increased lability of affect. “How are you feeling now?” many patients will say. anxiety. affect comprises not only stated mood but also eye contact. fear. disgust. drumming fingers. For people who cannot tell you how they feel (alexithymia). guilt. Reduced lability of affect we call blunted or flattened. Ask. a fixed stare could mean senility or psychosis. or show any other evidence of speech impediment? Note any mannerisms of speech. sadness. twisting fingers. . affected nonchalance (such as picking one’s teeth) Sadness: moistening of eyes. “about normal” or “medium. mumble. joy. suggest some of the possibilities mentioned above. including phrases or words used frequently. hostile? You can describe your patient’s apparent relationship to you along several continua: Cooperative → obstructionistic Friendly → hostile Involved → apathetic Open → secretive Your rapport and the amount of information you obtain could depend in part on how far to the left your patient scores on each of these factors. slowed movements Shame: poor eye contact. posture. wide swings are often abnormal. shame. stutter. schizophrenia. drooping shoulders. “Did you feel this way when your [relative] died? Lability Although normal people may experience different moods within a brief time span. Also note any evasiveness or seductiveness. Mood and affect Some clinicians use mood and affect interchangeably. love. facial expression.

there’s the absence of feeling or emotion that we commonly call apathy. Association Does your patient speak spontaneously. Instead. I’ve adopted the best consensus view. this type of inappropriate mood is called la belle indifference (French: lofty indifference)..g. Think spring fever. which is where I never want to be. one so the direction of the words seems controlled by rhymes. let alone these definitions.” Flight of ideas is a form of derailment in which one idea takes off from another. what we actually perceive is the flow of speech. with the patient eventually losing the thread of the original question. but in and of themselves.) Defects include 1) association (how words are grouped to form phrases and sentences) and 2) rate and rhythm of speech. or other rules—but not by logic you can understand. and King Kong never knocked out New York. Remain alert for signs of unexpressed emotion. Psychiatrists often can’t agree on where to have breakfast. “She tells me something in one morning and out the other. or severe (think of the progression from dysthymia through major depression without—and then with—psychosis). Does the current topic warrant tears? Does your patient appear unnaturally sad? Is that smile genuine or does it seem forced. or only in response to questions? If you haven’t yet had a run of free speech to evaluate the quality of your patient’s thinking. but you should illustrate your findings with direct quotations. but marked incongruity suggests disorganized schizophrenia (e. on the back wards. or somewhere in between. one idea runs into another. Finally. That’s d-l-r-o-w world backwards. avolition (lacking motivation or desire). It and its fraternal twin. Get it? Tangentiality (or tangential speech) is an answer that seems irrelevant to the question asked: . sometimes called loose associations. the result of various disorders such as multiple sclerosis and strokes.” “I’ve got to put the kettle out. possibly related.Interviewing Appropriateness 19 How well does your patient’s mood match the situation and content of thought? Most of us exhibit inappropriate mood from time to time.” In derailment. laughing at the death of a parent). my favorite place in the whole world. Flow of thought How do the patient’s thoughts move along from one to the next? (Of course. You might also consider whether the mood is fleeting or prolonged. moderate. Pathological affect (inappropriate crying or laughing) sometimes occurs in pseudobulbar palsy. from which we infer thought. better ask: “I think I could get a better feeling for what’s bothering you if you just talk about your problems for a bit. are often associated with psychosis and severe depression. relate what you observe to what the patient says and to how you think you yourself might feel under similar circumstances. but don’t overinterpret. in our family Mom was king. Mania patients often have flight of ideas and talk very rapidly (push of speech): INTERVIEWER: Can you tell me about your relationship with your mother? PATIENT: Sure. puns. Some somatization disorder patients talk about their physical disorders with less concern than you hear on the weather report. my taxi died. perhaps to hide true feelings? Intensity You can grade intensity of mood as mild. they are not pathological.

Sometimes subtle.” Sometimes termed word salad. Real close. Deathly still. Housman) Clang associations. A phrase includes repetitions of similar sounds. be sure to record it with a direct quotation. You must distinguish it from neurological aphonia. Without obvious purpose.” Perseveration. E. In the absence of artistic intent (such as Lewis Carroll’s Jabberwocky— “’Twas brillig. Deathly. . The choice of words is controlled by rhymes or other similarity of sound. often from parts of dictionary words. The patient repeats words or phrases or keeps returning to the same point. muteness ensues. Poets often use it for effect: “The street sounds to the soldiers' tread/And out we troop to see…” (A. INTERVIEWER: Can you tell me about your relationship with your mother? PATIENT: Relationship with my mother. When severe. When you do encounter an example. She’s calm. • . INTERVIEWER: Can you tell me about your relationship with your mother? PATIENT: Oh Mom. . . poor Mom. Still deathly. Can you tell me about your relationship? With my mother. Deathly. INTERVIEWER: Can you tell me about your relationship with your mother? PATIENT: Mom and I were close. Neologisms. the patient continues to repeat words or phrases. . but any may occur in psychoses of cognitive origin. before arriving at the station. INTERVIEWER: And your father…? PATIENT: Mom was my best friend. lifetime . and occasionally in somatization disorder. • • • Verbigeration. Even individual words or phrases appear to have no logical connection: “Shovel. . The patient usually doesn’t know why. it wasn’t the. Most occur classically in schizophrenia. “It was deathly still. schizophrenia. only that the thought has been “forgotten. and the slithy toves / Did gyre and gimble in the wabe …”)—the patient makes up words.” Alliteration. 20 A patient who answers too briefly or who sits speechless shows poverty of speech. A number of terms describe speech pathology you don’t often encounter in clinical interviews. The patient unnecessarily repeats words or phrases. . real close.Interviewing INTERVIEWER: Can you tell me about your relationship with your mother? PATIENT: My golf balls got pink dimples. The train of thought stops suddenly. Poverty of speech can be found in depression. • • • Thought blocking. you might not recognize it until there have been several repetitions. The resulting structure may sound authentic: An Alzheimer patient spoke of “rakebucketing in the garden.” Incoherence. a damn warm dam… • Echolalia. best hatred. rather than the requirements of communication. INTERVIEWER: And what about your father? PATIENT: Mom and I were buddies.

The words routine and normal help soften questions that might otherwise be taken amiss. Extraneous sounds or motion may temporarily send the speaker’s words off in a new direction. and if you put it off. Here are some other steps you can take to motivate your patient: • • Give positive feedback when warranted. and the patient’s native language. For most people. Some patterns are usually normal: • • • Circumstantial speech. you’re likely either to forget it or ignore it. Content of thought This means. mentally subtracting sevens can be hard. Depressed patients may have increased latency of response. “That’s terrific. Because speech patterns can be shaped by cultural or geographic influences. Disorders of rhythm of speech involve abnormal timing of syllables. Rate and rhythm of speech Push of speech (or pressured speech) occurs when someone speaks rapidly. tangle-tongued and disorganized. Distractible speech. some so basic as to seem insulting. Let’s give it a rest and try presidents. such as in stuttering. Accent. “Yeah. Cluttered speech is rapid. such as an American who affects a British accent or uses British idioms. the focus of an individual’s thought at any given time. Loud and hard to interrupt. Patients with cerebellar lesions may utter each syllable at such a uniform pace that the speech sounds unnatural.” Watch for any distress your questions might cause and respond appropriately. We all use these time-fillers. Verbal tics. Bottom line: Take care when evaluating your patient’s manner of speaking.” Do the formal part of the MSE early in your acquaintance—you need the data base information. who may say that their words can’t keep pace with their thoughts. So you should probably start with the brief explanation that you now need to ask some routine questions. Muscular dystrophy may produce speech clusters or difficulty uttering syllables. what you hear may carry no pathological significance at all. Though usually normal. or word choice gives speech an unnatural or quaint flavor. Both of these are typically found in mania patients. the best calculations anyone’s done for me this week. with long pauses between words. by neurological disorders. the person eventually comes to the point. often at great length. for most . such patients challenge your interviewing ability. which are almost always normal (but boring): “Y’ know” — “I go” (for “I said”) — “Basically” — “Awesome” Mental Status Exam—Cognitive Aspects The balance of the MSE requires you to obtain answers to questions. you’ll note that the content of thought is largely the concern that brought them for evaluation. After much irrelevant material. There may be accompanying general psychomotor retardation. you may note it in mania. phraseology. instead. There is often an associated decreased latency of response (the interval between your question and the patient’s answer).Interviewing • 21 Stilted speech.

the patient has committed some grave sin or error (for which punishment may feel deserved). that news media contain special messages for them. . Psychiatric patients can experience quite a variety of delusions: Grandeur. and they cannot possibly have abducted you into their space ship? PATIENT: I’d say you were crazy. Imminent destitution will force sale of the homestead and other property. Jealousy. A patient thought that when Jim Lehrer on the Newshour said that a settlement was imminent. race. Mania patients classically have grandiose delusions. or microwaves. Paris Hilton) or has special powers or gifts (enormous wealth. The patient’s spouse has been unfaithful—classically encountered in alcoholic paranoia. Sometimes.” the idea isn’t a delusion. or otherwise interfered with. Overvalued ideas are held despite lack of proof of their worth. or that they control the environment (one patient believed her tears could spawn hurricanes). Influence (or passivity). A delusion that the patient has died. These patients “notice” that people whisper when they pass by. Poverty. some of which you need to ask about. One of the more common types of delusion. By fixed. Reference. Severe depression. Examples include the superiority of one’s own gender. Typically found in paranoid schizophrenia. we mean that you cannot shake the person from the idea. TV. Though found in other psychoses. A terrible disease has rotted the patient’s insides or turned bowels to cement. Guilt. nor children who write letters to Santa Claus. ridiculed. Delusions 22 A delusion is a fixed. Especially found in severe depression. I was probed. false belief not explained by the patient’s culture. The false belief is that the patient is someone of elevated rank or station (God. despite money in the bank or a regular disability check. sometimes in delusional disorder. all right. However.Interviewing outpatients it will seem pretty normal. logic won’t usually dislodge them. If the patient agrees that your alternative explanation is possible or says “I’m just not sure. it meant that he should agree to the property settlement with his former wife. Paranoid schizophrenia. but also in paranoid schizophrenia and paranoid disorder. they interfere with the individual’s functioning. eternal life). The patients believe they’re controlled from the outside by such influences as radio. as with racial hatred. is an extreme case. Persecution. the patient’s belief is in being threatened with harm. but so do some patients with schizophrenia. Though not obviously false. Occasionally found in severe depression and schizophrenia. sometimes called nihilistic. INTERVIEWER: What would you say if I told you that there are no aliens. It must also pass the cultural criterion: you wouldn’t call a traditional Navajo delusional for believing in witches. INTERVIEWER: Could your idea be due to a nervous or mental problem? PATIENT: No way. causing suffering to the person or to those around. especially common in paranoid schizophrenia. psychiatric patients can have a variety of thoughts that aren’t at all normal. or religion. Ill health or bodily change.

the patient’s own thoughts are spoken so loudly that others can hear. prolonged alcohol use. perhaps by radio waves. though patients with delirium or dementia may report them. In addition to type. Similar to delusions of mind-reading. You can grade auditory ones. Here. perhaps commenting on the patient’s behavior (these have been called “first rank” symptoms of schizophrenia)? Does the patient recognize the speaker? Where is it coming from?—The patient’s head? The toaster? Next door? What is the content of the speech. I also like to know whether there is more than one voice. Another confound is the illusion. do they talk to one another. patients think they perceive something absent any actual. and is readily acknowledged once the patient realizes the mistake. A common example: clothes thrown over a bedside chair look like an intruder. which often yield little new information. You can similarly grade visual hallucinations: Points of light → blurred images → formed people (how big are they?) → scenes or tableaus. Try to determine the severity of hallucinations. Images linger on the retina in the trailing phenomena that sometimes . In the throes of delirium tremens when withdrawing from heavy. discount “no” answers. as for auditory ones. “Is the voice as clear as mine?” Again. Hallucinations Hallucinations are false sensory perceptions. When do they occur (only when using drugs or alcohol)? What is the content? How does the patient respond? (It can be pretty frightening—as one of my patients discovered upon looking into a mirror and noting that he had the face of a camel. Careful questioning can usually sort out these false positives. How long has the patient felt that way? What effect has it had on behavior? How does the patient feel about it? Why does the patient think this is happening? (I don’t normally like “why” questions. that is. suitably altered. ideas. Although hearing is the sense most commonly involved among psychiatric patients. 23 Thought control. patients may see tiny people or animals.) You’ll especially encounter visual hallucinations in the cognitive psychoses. Similar to ideas of influence. learn all else you can about the delusion. Ask: “Could [this voice] be coming from you. The patient’s thoughts are somehow transmitted.) Is the delusion mood-congruent—does the content fit the patient’s mood? A severely depressed man’s belief that he has gone to Hell and is being tormented by devils is moodcongruent. on a continuum: Vague noises → mumbling → understandable words → phrases → complete sentences. and if so. does the patient obey? This last is an important point: patients who obey command hallucinations sometimes cause injury—or worse. hallucinations can involve any of the traditional five senses. or thoughts are put into (thought insertion) or withdrawn from the patient’s mind. It is usually visual. Moodcongruent delusions are typical of mood disorder. like your own thoughts or conscience?” A patient who admits that it could be “noises out in the hallway” or “my imagination” probably doesn’t have true auditory hallucinations. related stimulus. mood-incongruent of schizophrenia. Schizophrenia. In audible thoughts. an angry woman who believes she is Jesus has a mood-incongruent delusion. Feelings. occurs in dim light. and how does the patient react? If the voice issues commands. a “why” question might elicit elaboration of the delusion. with similar diagnostic import.Interviewing Thought broadcasting. You can ask a lot of the same questions. You can ask. a misinterpretation of an actual sensory stimulus. Illusions are almost always normal. Screen for hallucinations by asking. for example. “Do you ever hear voices or other sounds when no one is around to produce them? Do you ever see things other people cannot see?” Some patients claim auditory hallucinations when they actually hear only your voice or their own thoughts.

no surprise. and writing (“I hate it when people see my hands shake”). Sometimes. dyspnea. Obsessions and compulsions often go together. Just telling one’s problems to another person is a relief. closed spaces. and often a brisk startle response. or time). belief. and what helps. how often they occur. students are unlikely to have this opportunity while they are still learning the ropes. They both occur while awakening. That brings up another point: Any interview can be therapeutic. Such patients often feel they are about to die or go mad. itching. money. such as temporal lobe epilepsy. the fear of being away from home or “trapped” in a public place such as a theater or supermarket and unable to get out? A phobia is any unreasonable.” Anxiety symptoms Fear that isn’t directed at (or caused by) something the patient can pinpoint we call anxiety. or following rituals. Screen for anxiety symptoms with: “Do you feel you worry about things out of proportion to their real danger?” “Do you often feel anxious or tense?” “Do relatives or friends call you a worrywart?” Follow up by defining when the worries occur. heights. and their effect on the patient’s life. Specific phobias include air travel. the “verbal laying on of hands. intense fear associated with a situation or object. patients usually recognize them as senseless and often try to resist them. or in public places such as stores or on bridges?” Ask about anticipatory anxiety—intense. or idea (they commonly involve dirt. even though you try to resist?” . often incapacitating dread that precedes the actual event. but once you’re in practice. I could affirm her sanity by explaining that she had experienced a combination of hypnopompic imagery with sleep paralysis. there are also unpleasant bodily sensations. often to combat an obsession.) A woman told me. and a zoo-full of animals. counting things. how long the attacks last. Compulsions are acts the patient performs repeatedly. their effect on the patient’s life. or of bugs crawling on or under the skin) and olfactory hallucinations (unusual odors. but keep returning anyway. using a public urinal. “Early one morning I saw the Devil standing over my bed.” “Have you ever had compulsions—such as rituals or routines you feel you must perform over and over. or of being in crowds.Interviewing 24 accompany psychedelic drug use. and sweating is having a panic attack. Schizophrenia patients can also experience visual hallucinations. but that you just couldn’t shake?” “Have you ever been afraid to leave home alone. worrying. An obsession is a dominating thought. I was totally awake but paralyzed—couldn’t move my arms or legs! I was so frightened. Screen: “Have you ever had obsessional ideas? I mean thoughts that may seem senseless to you. Screen by asking: “Have you ever had a panic attack. along with other mental symptoms that include irritability. weakness. Of course. trouble concentrating. Are attacks associated with agoraphobia. A person who suddenly experiences intense anxiety with the rapid onset of sensations such as tachycardia. Tactile hallucinations (sensations of burning. early forms of which may include objects that change size or develop intense colors. Usually. you can experience the pleasure of helping another human being with the simplest of devices. clinicians can provide reassurance without derailing the information-gathering. Social phobias include speaking or eating in public. when you suddenly felt terribly frightened or anxious?” Follow up by learning all the other symptoms the patient might have had. Screen for phobias: “Have you ever had fears that seemed unreasonable or out of proportion. often unpleasant) are likely to indicate the presence of a psychosis caused by physical illness. such as heeding baseless superstitions. Am I crazy?” Happily.

but also consider sarcasm from an angry or uncooperative patient. The process (confabulation) isn’t lying. if my patient mentions a date years ago. but you should test time and place. so be prepared to support the patient who stumbles: “It’s hard to do your best under pressure” or “Most people have trouble with that task. If there is any confusion about place or time. We sometimes use calculations to asses these qualities. Ask “Where are we right now?” (City. interpret cautiously the rest of your MSE findings. if attention is impaired. education. schizophrenia.Interviewing Suicide and violence (again) 25 Because this topic is so important. “Then. If you draw a blank stare. “What is the date?” Lots of patients will get the year and month right but be off a day or two. Ask the patient to subtract 7 from 100. Reduced attention can be found in conditions such as epilepsy. For example. why do them at all?” I also avoid the word “simple. so you might try spelling strap or watch backward (first make sure the patient can spell it forward). “And how old would you have been then?” If subtractions prove too hard. Much of our mental processing depends on the ability to focus attention. and communicate information. evaluate orientation to person: “Would you tell me your full name again?” Some disoriented patients try to hide their mistakes with made-up responses that sound logical. but you must take into consideration the person’s age. culture. you should have a good idea of your patient’s attention (the ability to focus on a topic or task) and concentration (the ability to sustain focus over time). because these people seem to believe what they . especially for a retired.” which could increase the discomfort of anyone who has trouble answering. always. this is normal. try a less culture-bound test: “Count backward by 1s from 87 and stop at 63. state.” Spelling world backward is asked so often that some patients can rattle it off without thinking. Does the patient have plans? The means (guns. process. head injury. lethal drugs)? A timetable? Consciousness and cognition Here.” And. then backward. I often try to get a rough idea by introducing a subtraction task in the course of my interview. “Nothing could. and bipolar disorder. you use approximate (but useful) clinical tests to evaluate the patient’s ability to absorb.” For violence: “Have you been feeling so angry or upset that you think about harming someone else?” “Have you ever had trouble resisting the urge?” Positive answers must be followed at once and compared with the historical information you already have. try “What sort of a building is this?” “A museum” or “The World Trade Center” suggests severe pathology. and so on. I might say. acknowledge what the patient does well. depends less on education. dementia. Most adults can finish in less than a minute with fewer than 4 mistakes. and degree of depression and anxiety. name of facility). Usually. The screens: “Have you any ideas or thoughts of harming or killing yourself?” “What would it take to make suicide seems less attractive?” Regard as ominous any equivalent to the answer. Doing poorly on any test can be stressful. then take 7 from the result. older patient or a hospitalized person who doesn’t have a normal routine to provide cues. I never describe these routine tasks as “silly”—that risks the question. I mention it again as a reminder. Orientation You’ll probably already know whether your patient is oriented to person. Attention and concentration By now. Recalling a series of 5 to 7 digits forward.

” Fluency. clip. said.” Reading is quickly tested by asking the patient to read a sentence or two.” though I don’t think I’ve ever read the reason why. down in the bar. • • • Comprehension should be evident from your interview.” Test repetition by ask the patient to repeat a simple phrase. You can assess it again on your way to testing short-term memory. mumbling. For example. which you’ve already tested with serial sevens or counting.” You may encounter confabulation in thiamindeficient patients severely impaired with amnestic disorder due to chronic alcoholism. and writing. barrel. births of children. Memory We commonly assess immediate. • • • Problems on any of these screening tests should prompt a neurological evaluation. psychosis. put it into your pocket. Hysteria. Should you alert patients that you plan to test them later? One school of thought advises “yes. color. I prefer not to warn. then return it to the table. request this complex behavior: “Pick up this pen. Test writing by asking your patient to write any sentence or one that you dictate. Experts disagree about the dividing line between short-term and long-term . as long as you are consistent.Interviewing 26 are saying. As a simple test. This repetition also provides assurance that the patient has understood you. You can best assess long-term (remote) memory from the patient’s ability to relate the history of the present illness and facility with details of marriages. A patient with a naming aphasia might call a watch band “The thing that holds it on your wrist” or a pen “A whatsis for writing. Language Language. reading. Most will repeat the name. test short-term (recent) memory by asking your patient to recall the three items. Name several unrelated items (I use a name. includes comprehension. asked whether he had ever met the interviewer before. and long-term memory. then ask the patient to repeat these items. a ward patient. and other mental conditions are sometimes misdiagnosed when the patient actually has a disorder of language. Five minutes later. The other points out that any warning invites cognitive rehearsal. a color. which could mean that a patient benefits from practice—and perhaps pays insufficient attention to the questions you ask in the meanwhile. naming. stammering. and at least part of the address. Failure on all three tasks suggests serious inattention due to a cognitive disorder or stress from depression. Watch for hesitation. intermediate. Problems with naming may be evident from the use of circumlocutions to describe everyday objects. and unusual emphasis. repetition. the means whereby we use words and symbols to express and understand meaning. “Oh yeah! It was last night. dementia. and a street address). fluency. such as “Tomorrow will be sunny. and other personal information. be sure to consider your patient’s apparent motivation. When evaluating the results. Its assessment is especially important in older and physically ill patients. Immediate memory (the ability to register and reproduce information after 5 or 10 seconds) is really a matter of attention. What you want is a feeling for the range of normal response. Screen for aphasias by asking the patient to name the parts of a ball point pen: point. or anxiety. but the issue may be more cosmetic than cosmic—perhaps either method’s OK.

so you are probably better off asking some of these: “How are an apple and an orange alike?” (Both are fruit. Eventually. Commonly used abstractions include proverbs. You’ll encounter amnesia. similarities. You could also ask. spherical. in head trauma. though. Cultural information These tasks mainly assess the patient’s remote memory and general intelligence. so some texts don’t even mention them. “He’s hiding between two Bushes. however. alcohol blackouts. so that memories stored long-term are not easily forgotten. five large cities. Abstract thinking The ability to abstract a principle from a specific example is another traditional task that depends heavily on culture. working backward. it’s fair to try to jog your patient’s memory. “Have friends or relatives tried to help you reconstruct what happened?” Don’t assume that a memory hole means something bad happened—clinicians have come to grief persuading patients that amnesia implies assault or molestation. and differences. did you leave out anyone?” or. intelligence. Similarities and differences are somewhat less culturally bound than proverbs.) “How do a child and a dwarf differ?” (A child will grow. or five rivers. patients with severe dementias such as Alzheimer’s will lose even long-retained information. the temporary memory loss due to physical or psychological trauma. They are. what’s the first thing you can recall afterwards?”).” Other cultural tests are to name the governor of the state. have seeds. and education. but most agree that between 12 and 18 months some sort of consolidation takes place. PTSD. If one is omitted. candidates in the next election. Accept any logical interpretation.) Insight and judgment Insight refers to your patient’s ideas about what is wrong. It may be evident. “What does it mean when someone says that people who live in glass houses shouldn’t throw stones?” “Can you tell me what this means—A rolling stone gathers no moss?” Note that some proverbs have more than one interpretation (moss-gathering might be regarded as either a positive or a negative). and interests by asking about current sports events. the notorious false memory syndrome. memory.” You might try: “Have there been periods of time that you cannot remember at all?” “Have others ever noticed that you have trouble with your memory?” Try to determine whether amnesia is fragmentary (the patient can remember isolated bits) or en bloc (complete loss of memory for that time). It can be hard to ascertain—the natural answer to “Have you ever suffered from amnesia?” is “I don’t remember. a traditional part of the mental status exam: “Who is president now? Who was just before?” Most patients can name four or five presidents. “Let’s see. but you can ask: “Do you think there is something wrong with you?” .Interviewing 27 memory. and other cultural items. and dissociative disorders. You can also get a pretty good idea of your patient’s intelligence. You might try to bracket the memory hole with the memories on either side (“What’s the last thing you can recall just before the period of amnesia.

posttraumatic stress. severe depression. Can a clinician safely avoid asking the questions contained in the cognitive portion of the mental status exam? For students. Great fun for professional interviewers (viz. whereas volume 2 introduces more specialized techniques for “difficult patients” who are psychotic. . and any of the psychoses.” What I’m really asking is. Patients’ assessment of their own strengths—what they think they are good at—can be important for recommending treatment and estimating prognosis. you’ll encounter all of these elementary mistakes in a single. dissociation. Some writers still recommend assessing judgment with hypothetical questions such as “What would you do if you found a letter with a stamp on it?” or “How would you react if a fire broke out in a crowded theater?” I avoid such questions. Insight also tends to deteriorate with worsening illness and to improve during remission. “Never. Poor insight is typical of cognitive disorders. the answer is “No. which probably have little bearing on real patients in the real world. deceptive. by Ekkehard Othmer and Sieglinde C. Or ask: “Do you think you need treatment?” “What do you expect from treatment?” “What are your plans for the future?” When Can You Omit the MSE? Because you derive much of the MSE by observation alone. or nil—a mania patient with partial insight might realize that something is wrong but blame others for it. Sometimes. and somatization. from which the chapter above was précised.Interviewing “What kind of illnesses do people come here to get treated for?” “What are some of your strengths?” “Do you think you are impaired in any way?” 28 Insight may be full. cognitively impaired. questions so complicated that you cannot follow the thread. Further Learning Interviewers on TV or radio provide a terrific opportunity to study interview technique— sometimes to experience the opposite of what I recommend. The Clinical Interview Using DSM-IV-TR. or who may use symptoms as meta-language—such as those with conversion.” because you should be learning what to ask and what answers to expect from normal (and abnormal) people. Volume 1 covers the fundamentals of interviewing. all of us) to use as examples of how not to elicit information. Byzantine utterance. A one-volume approach is taken in The First Interview.. both of which you’ll find in the OHSU library. But an experienced clinician will sometimes omit the formal questioning when faced with an outpatient who presents a well-organized history or when the results of formal testing are available. Othmer is in two volumes. Evaluate your patient’s selfimage with: “What do you like about yourself?” “How do you think others people see you?” Judgment is the ability to determine an appropriate course of action to achieve realistic goals. partial. You can get much more information on interviewing from a couple of books. I’m thinking of certain talk or news show hosts whom you can catch asking double questions. the real answer is. In the final analysis. your best appraisal of judgment may come from the history you have just obtained. leading questions.

Specific goals include predicting treatment outcome. The features that were identified for many categories of patient provided the basis for what eventually became DSM-III. or tonsillitis. not bipolar disorder or a substance-related psychosis. we can achieve the intended purpose of any diagnosis: to make accurate predictions of what to expect in the future. The hard-headed demand that conditions we diagnose meet strict criteria also helps us avoid those diagnoses that are too vague or too ill-studied to have predictive value.Chapter 2 Making a Psychiatric Diagnosis Until the middle years of the Twentieth Century. why do we need criteria. not science. With that assurance. judging which family 29 . anyway? Other medical specialties don’t count symptoms—for a broken femur. The DSM-IV system of diagnosis In the 1970s. a schizophrenia patient would still have schizophrenia. for example. wait a minute. whereas British psychiatrists tended to favor bipolar disorder. This finding reinforced a movement. The realization that this Wild West approach to diagnosis was producing some unhappy results for American psychiatrists (and their patients) led to a philosophical sea change. Those Washington University psychiatrists (and researchers today) validated the syndromes they identified with follow-up studies on the premise that. the US–UK Cross-National Project determined that American psychiatrists were far more likely to diagnose schizophrenia in any given psychotic patient. partly because there are too many matters about which clinicians would not otherwise agree. the first diagnostic manual that stated criteria for diagnosis. years down the road. But. validly diagnosed conditions wouldn’t morph into something else. championed by psychiatrists at Washington University in St. they were likely to be idiosyncratic and based on intuition. psychiatric diagnosis was pretty much a freefor-all. Louis and other research institutions. That’s why we count things. Researchers’ reexaminations of the patient records using a conservative definition of schizophrenia largely agreed with the British clinicians’ diagnostic impressions. If psychiatrists followed any rules at all for making a diagnosis. to discover patient characteristics that allowed reliable groupings. We’ll briefly explore two aspects of this paradigm shift. Psychiatrists use criteria partly because we have so few definitive laboratory or imaging studies.

and substance use disorders—all except * the two listed on Axis II. It includes five information areas. † * The DSM-IV manual includes numerous GAF examples. we don’t need to worry about them here.. thinking. and helping patients understand their options. interpersonal) that could influence the diagnosis or management of psychiatric patients.* Axis II Axis III Physical conditions and disorders. Personality disorders and mental retardation. These are the events and conditions (e. cognitive. most (but not all) of which have been identified in careful epidemiologic studies. family relations) 21–30 Behavior shaped by delusions/hallucinations or seriously impaired judgment or communication 11–20 Some danger of harm to self or others or failure to maintain minimal personal hygiene or grossly impaired communications 1–10 Persistent danger of severe harm to self or others or persistent failure to maintain personal hygiene or serious suicidal act 0 Inadequate information You’ll find numbers (and a few letters) tacked onto the diagnoses associated with Axes I–III. job. This scale reflects overall social. These are coding devices for the folks in the record room. explaining the natural history of the disorder. slight. if any. job. . each called an axis: Axis I Mental disorders. despite which DSM-IV remains the best system yet devised.* mental condition or treatment. no symptoms 81–90 Few if any symptoms. psychosis. it is most useful in tracking a patient’s progress across time. Axis V Global assessment of functioning (GAF). Listing these on a separate axis helps ensure that they won’t be overlooked. social impairment 61–70 Some mild symptoms or some problems in functioning 51–60 Moderate symptoms or moderate problems in functioning 41–50 Serious symptoms or serious impairment in functioning 31–40 Some impairment of communications or reality testing or major impairment in several areas (work. these include every category of mental diagnosis. legal. such as mood. Requiring strict criteria.† 90–100 Functions well in a wide range of activities. good functioning in all areas 71–80 Any symptoms are transient and expected reactions to stressors. it has flaws. Some of them may have a bearing on our patient’s Axis IV Psychosocial and environmental problems. Of course. work and psychological functioning. housing. Our current diagnostic system comprises over a hundred categories of mental disorder. Each requires criteria. judgment. economic.g.Diagnosis 30 members are at risk for similar diseases.

So. even if you can flesh it out with diagnostic criteria. Once we’ve decided about anything. These may include a variety of disorders. This is terrific efficiency. need for a welldefined diagnostic procedure. that’s just plain wrong. a man who has had schizophrenia for the past 12 years and who has for several years been heavily using alcohol. but it puts us at enormous risk for error. then scrupulously observe each returning patient for new information. and psychological testing data Identify all relevant syndromes. including mood. Each of the types of syndrome you identify could have a variety of causes. substance use and many others. our past experiences. Many patients will have elements of several syndromes. psychotic. Assuming that our interviews and reviews of available information had validated the impressions stated above. 3) medical records and other healthcare providers. Create a wide-ranging differential diagnosis that includes all possibilities. here’s how we’d report our evaluation: Axis I Axis II Axis III Axis IV Axis V Paranoid schizophrenia. chronic Alcohol dependence Schizoid personality disorder None Currently in jail No network of support GAF = 25 (current) However. Hence. Repeated studies have shown that experienced psychiatrists tend to make a diagnosis within the first 3 minutes of the initial interview. He is a lifelong loner with no friends who. human nature causes us to look for information that will reinforce that decision rather than call it further into question. under the influence of auditory hallucinations. a mood disorder could be due to major depression. Diagnostic procedure A big problem with the DSM-IV is that too many clinicians have come to assume that simply collecting a batch of symptoms relieves us of responsibility for any real thinking. Here in the 21st Century. and so forth. anxiety. physical illnesses. imaging. 2) collateral interviews with relatives. But following the outline below should help ensure that you consider—and reconsider—all the relevant material. Let’s say this is the inmate of a jail. On a given day.Diagnosis 31 Here’s how we might use the 5-axis structure to describe a patient. One antidote to this sort of choice-based blindness is to follow a careful routine when evaluating each new patient. 4) laboratory. there is no such thing as a fail-safe diagnostic process. Our initial impressions. substance use. and our expectations combine to endanger future objectivity. you could conceivably find enough symptoms in most patients to suggest a variety of diagnoses that wouldn’t necessarily be correct. Collect all relevant information from 1) interviews with the patient. isn’t nearly enough. dysthymia. Of course. just knowing the skeleton. • Assemble a complete database. broke into a church and desecrated the altar. • • .

Peculiarly enough.) If you prefer the shorter. In any differential we should list the diagnostic possibilities so as to expose our patients to the least possible risk—of perils such as social stigma. at the top those conditions that most urgently require treatment. are most likely to respond well. Although schizophrenia can be managed successfully. Keep your mind open. Choose your best diagnosis. Most especially you should consider the possibility that any disorder could be due to a medical illness or substance use. Alzheimer’s. prognosis that is wildly inaccurate. it is often difficult to treat and it sometimes results in agonizing years of disability. and antisocial personality disorder. but constantly reevaluate as new data emerge. Everything else goes somewhere in between. Diagnosis Made Easier comprises what I’ve learned in 40 years about sifting information to make a psychiatric diagnosis. a rule to which psychiatric patients prove no exception. Further Learning For the official word on current American psychiatric diagnoses. the diagnostic process is something that most psychiatric texts don’t pay much attention to. That means. are most likely to respond well. there is a copy of Morrison’s DSM-IV Made Easy in the OHSU library. though clinicians can (and do) argue about the exact order. treatment that is inadequate or downright harmful. but recurrent depressions and even bipolar mood disorder also belong in this category. . A safety hierarchy places at the top those conditions that most urgently require treatment.Diagnosis • 32 Arrange your differential diagnoses in the order of a safety hierarchy. At the bottom are conditions where a terrible prognosis makes treatment seem unlikely to make much difference—disorders like AIDS-related dementia. • Differential diagnosis and the safety hierarchy A wide-ranging differential diagnosis is vital to the evaluation of any patient.” which means that the supporting text reflects the latest research. A safe diagnosis is one that you’d prefer for yourself or a family member—if it turns out to be correct and leads to effective treatment. But most important still is to consider first those psychiatric causes related to substance use or medical illness. or social interventions that are inappropriate or unnecessary. There’s a copy in the OHSU library. and have the best outcome. the latest edition of the diagnostic and statistic manual—DSM-IV-TR—provides 900 pages of light reading for a Saturday night. there are also a few minor changes to the criteria for just 3 diagnoses. nonofficial version with case histories. and have the best outcome. (TR stands for “text revision.

“I used to have a passion for bridge. and she didn’t drive).” For about 5 months.Chapter 3 Depression “It was the insomnia that got my attention. being with people didn’t help her shake off the constant fatigue. Though most people won’t have them all. It can last just a few days or weeks or many months or years. “And I’ve been so irritable with Jack. “I’ve never felt depressed and worthless like this before.” After a medical checkup revealed she was physically healthy (and that she had never used alcohol or drugs). it is a profoundly painful gloom. losing interest in things she usually enjoyed. Some are almost guaranteed. a favorite hobby. she had little appetite. I’m lucky he didn’t just leave me. “I’ve always slept like I was drugged. I just sit and stare out the window. Suzanne was referred to a psychiatrist. now it seems so trivial. it may be nothing more than a gentle sadness.” Suzanne told her PCP. let alone see them.” Instead. he had urged her to seek help. I haven’t got much energy for anything. so she’d cut back to part time. changes in appetite and weight. and now relied on fast food and TV dinners. the stress of her job—she worked at home for a dotcom marketing firm—had been getting to her. Symptoms of depression Clinically depressed patients will experience a number of symptoms. even pain or weakness.” Recently Suzanne had become listless. whereas others are less common. She said she’d never before felt so miserable and often found herself crying “over nothing. fighting back tears. for others. to whom she repeated her story. had even made the call for her. such as crying. For some. she had stopped cooking. I feel like I’ve lost my life. “I don’t even want to talk on the phone with my friends. so when I kept waking up at 3 in the morning. Some patients experience physical symptoms. “I didn’t have the energy to dial the phone. she said. wondered if she needed a change: perhaps she was just lonely (they lived far out in the desert. her husband. I knew something had to be wrong. difficulty with sleep.” Though her weight hadn’t changed. 9 core 33 .” she said. Jack.” The term depression embraces a variety of meanings. However.

Even trivial decisions come to seem impossibly complicated. or simply “down”—or other people think the individual looks depressed. Problems with appetite and weight. some depressed people instead sleep more than usual (hypersomnia). Patients struggle to fall asleep. Crying spells is one such symptom. Like Suzanne. In any event. a few even believe they had died and gone to hell. appetite declines and weight drops. despondent. They may experience hallucinations (tableaus of torture victims or accusatory voices shouting that the patient is evil). Then they feel tired and grouchy during the day. tiredness makes it hard for the patient to perform everyday tasks. Depression severity Some depressed patients become acutely psychotic. Of course. Fatigue. In a depressed state. Clinical depression lasts most of the time for at least two weeks. nearly every day. One patient said that just maintaining a thought was like trying to grasp a piece of soap that kept squirting away. Some patients complain of physical issues such as headache or an upset stomach. anguished. pulling hair. but most of these are more often found in disorders other than depression. it goes on for months. or they awaken throughout the night or (like Suzanne) too early in the morning. plans and attempts. When all thoughts are painful. However.Depression symptoms are listed below. Low self-esteem. when loss of interest extends to food. Guilt feelings make some feel that life has been a failure. The patient feels sad or some equivalent—mournful. it was cooking. Even with good sleep. meaning that the content of the delusion mirrors the person’s mood. 34 Depressed mood. like Suzanne. Patients care less about activities they used to enjoy. patients may feel nearly worthless (Suzanne did). Thoughts of death. depression is wearing. Severe guilt feelings can evolve into a delusional belief that they deserve to suffer for their sins. Note that to qualify as diagnostic criteria for major depressive episode or dysthymia. Many depressed people become restless. time passes slowly and everything looks gray. Problems with sleep. these symptoms must be present most of the time. that they have let everyone down. only the symptoms boldfaced above qualify as criteria for a DSM-IV mood disorder. to the point that somatic symptoms have at times been regarded as depressive equivalents. In Suzanne’s case. They may wish they had been better people or “done things differently. wringing hands). many patients cry a lot. watching TV—even having sex—typically fall by the wayside. Repeated thoughts about death (not just the fear of it) can escalate to suicidal ideas. usually. it’s hard to focus on your responsibilities and other important matters. Depression slows others down. blue. but hobbies and interests such as reading.) Some patients feel . some depressed people have increased appetite or eat so much more than usual that they gain weight. so agitated they cannot sit still (pacing. Change in activity level. some. However. do little more than sit.” Poor concentration. irritability is another. you’ll encounter plenty of other symptoms. Loss of interest or pleasure. (Note how these delusional beliefs are nearly always egosyntonic. Classically.

Sleep becomes a nightmare. as described above. Hallucinations or delusions may appear. and they’ll continue with work and family life. or mixed—is present (we’ll discuss the last 3 of them in the next chapter). Those who still go to work don’t get much done. A DSM-IV diagnosis of any of the depressive disorders requires that other conditions be met. Mild. Severity is determined by a combination of several factors: the number of symptoms. and the likelihood of illness in blood relatives. they begin to have gloomy thoughts about death. hypomanic. Patients who are mildly ill will have just a handful of the symptoms listed above— barely enough to qualify for a “major depressive episode”—and they’ll cause only minimal inconvenience. where things will never improve. manic. appetite is gone. even iconic. These additional factors assure us that this particular patient qualifies for a category that has been studied and vetted enough that we can predict such issues as outcome. Severe. The future seems bleak.Depression 35 completely hopeless. These patients will probably still sleep and eat pretty well. As more symptoms accumulate. Following is a differential diagnosis in which the numerous depressive disorders are ordered in a rough safety hierarchy (see page 32). their intensity. or avoid them altogether. perhaps concluding that they are forever condemned to their own personal corner of hell. . response to treatment. perhaps they fight with fellow workers. The first is to determine whether one of the 4 mood episodes—major depressive. Differential diagnosis The presence of depressive symptoms isn’t by itself a real diagnosis. and the effect they have on patients and those around them. increasingly extreme. they begin to dominate the person’s life. Still more symptoms. failing appetite causes weight loss. In the case of any of the depressive disorders. These patients may plan suicide or make actual attempts. we are looking first for evidence of what DSM-IV calls a major depressive mood episode. likely. guilt feelings crowd out other thoughts. feelings of unreasonable guilt expand and deepen. Such descriptions are dramatic. but in their extremity they only fit the small minority of depressed people. Depression due to substance use Depression due to a medical condition Bipolar I or II Major depressive disorder Atypical depression Psychotic depression Recurrent depression Seasonal affective disorder Dysthymic disorder Adjustment disorder with depressive features Normal? Major Depressive Episode and Disorder The evaluation of any mood disorder should occur in steps. Insomnia yields daytime fatigue. the patient takes sick leave from work or school. Moderate.

the patient pinpoint when it began. poor appetite. You don’t have to include this stuff. After identifying the type of mood disorder. Several other qualities must be noted: the symptoms must occur for (1) a minimum time duration resulting in (2) clinical distress or impairment of work. and almost always they’ll agree that it’s a distinct change from normal. and seasonal pattern (Table 3). Her thoughts were gloomy (she felt she had accomplished nothing with her life). loss of pleasure. and that she’d never had an episode of mania or hypomania. Patients who don’t recover completely follow one of two general patterns: some . rapid cycling. but it might be helpful to someone down the road. This longitudinal information indicated that she had a single episode of major depressive disorder (MDD)—see also Table 2. “When did you last feel well?” Untreated (which happens far too often). and any episode intermixed with mania. Suzanne’s doctor noted that this was her first episode of depression. Some patients (mostly. Course of illness Major depression usually begins slowly and worsens over the course of a few weeks. though you might be able to approximate it by asking. and loss of interest in her usual activities. and about the course of illness (postpartum onset. full recovery. blue. you can add specifiers that apply to the current or most recent mood episode. or some similar description. there must be a total of 5 of the typical depressive symptoms listed on page 33. they may only identify a loss of pleasure or interest in activities they used to enjoy. Sometimes. and atypical features. bereavement within 2 months. not just a worsening of how they usually feel. the use of substances.Depression 36 Major depressive episode The first requirement for identifying a major depressive episode is a significant mood change. most depressions last several months—perhaps nine. though she wasn’t so seriously ill that she had psychotic symptoms or thoughts about dying. down. She noted that how she felt was markedly different from how she formerly felt. Major Depressive Disorder And now to the diagnosis of Suzanne’s actual mood disorder. that she had no substance abuse or medical disorder that could explain her symptoms. She also didn’t have symptoms that would make us think of schizoaffective disorder. Including the low mood or loss of pleasure. social life or personal functioning and (3) from which are excluded conditions brought on by the medical illness. This verbiage is valuable in that it can let the next clinician down the road in on your thinking about such clinical symptoms as melancholia. Patients feel depressed. With the patient’s collection of symptoms identified. Now we’ve defined the major depressive episode (see Table 1). A few people don’t recognize just how unhappy they are. the work is only partly done. the depressed mood (or loss of pleasure) must be present most of the day. trouble sleeping. on average—and resolve with a complete return to previous level of functioning. Note that there are several steps to the diagnostic process. Suzanne reported 6 of these: feeling depressed and worthless. most days for at least two weeks. low energy. that she hadn’t been depressed long enough for a diagnosis of dysthymia. catatonia. older people) will think the problem is something physical—a severe headache or abdominal pain—which earns the term “masked depression” and can require careful questioning to reveal the real problem. For a DSM-IV diagnosis.

Epidemiology. and we just don’t know the answer behind these sex differences. incidence estimates occur along a fairly wide spectrum. In the past several years. For example. but there is some overlap. but plausible. or marital status. whereas others may remain chronically depressed for years. Fanciful? Yes. only a minority of those who have suffered a loss (such as bereavement) will report symptoms of clinical depression. adolescents. but children. The important current thinking includes the following: Genetics. An enormous volume of research has explored the many theories about the etiology of depression.) It usually begins in the 20s or 30s. which then run their course. MRI. The brains of suicide victims have been found to have fewer than normal type 2 serotonin receptors. and senior citizens are also at risk. though we need to make an assumption to account for the fact that. though more people suffer from depression than any other mental health disorder. A person who loses a parent or other important figure or who suffers any other major disappointment in life (think job loss. you might think that depression is universal. say. Brain chemistry and structure. More recently. and drug treatment) implicate the subgenual cingulate area (Brodmann area 25) in patients with melancholia and other forms of major depression. boys and girls are about equally affected. In general.Depression 37 improve. though thus far. socioeconomic status. lost wages and other indirect costs exceed $30 billion annually. (In children. and the exact relationships have yet to be determined. the effectiveness of selective serotonin reuptake inhibitors (SSRIs) in treating depression have implicated serotonin as another neurotransmitter responsible for depression. Overall. How can we explain the possible etiologic role of loss and other stress? The stressful event might precipitate the release of. the relatives of patients who have only depression (no mania) also tend to have just depression. cortisol. etiology and comorbidity Because everyone feels sad from time to time. the number with diagnosable mood problems is still far below 50%. in most studies. the evidence has been largely indirect. Loss. Having a relative with depression enhances your own risk. unleashing the depressive symptoms. But. identical co-twins of depressed probands have about 4 times the chance of depression as do fraternal co-twins. rejection by a lover) may develop depressive symptoms. A number of studies (PET. In fact. direct costs of depression range upward from $12 billion each year. So we must postulate that our . small series of previously refractory depressed patients treated by direct deep brain electrical stimulation to this part of the brain have reported an immediate lifting of mood. an important metabolite of serotonin. There is no relationship to race. Major depressions are reported in all countries in the world. heredity explains half to two-thirds of the risk of depression. In the United States alone. Various studies find the incidence for women ranges from 10–25%. and the CSF of severely depressed patients are short of 5-hydroxyindoleacetic acid (5-HIAA). for over 40 years it has been known that the tricyclic antidepressants (TCAs) inhibit reuptake of norepinephrine at presynaptic nerve terminals and that monoamine oxidase inhibitor antidepressants inhibit its breakdown once it has been released into the synaptic space. A variety of neurotransmitters have been suggested as mechanisms for depression. men come in at just about half that. strongly supporting the role of genetic inheritance. but retain a few. low-grade symptoms of depression (partial remission).

in which people think of themselves in negative terms—feeling that they are worthless. For those who. in which case it is often important to determine which came first: depressions that occur secondary to the onset of substance use require a different treatment plan. Perhaps some people “learn” depression from past experiences where they could not avoid unpleasant situations. Other major mental disorders. no single theory will ever account for every depression. some patients develop symptoms of obsessive-compulsive disorder. the chemistry of the brain can be used to explain the final common path for depressions resulting from any of the above causes. clinicians should consider many explanations when evaluating patients. soon she was working full time again. Acute phase The choice of acute treatment hangs on four factors: its availability. an older drug such as desipramine (Norpramin) or nortriptyline (Pamelor) is a reasonable choice—these have fewer side effects than most other TCAs. helpless and hopeless. then. perhaps created early in life by abuse. The problem is. prevention of future episodes. cannot take one of the above drugs. . a different treatment approach may be needed—one that deemphasizes physical treatments such as medication. Within another 10 days her mood had brightened. Treating major depression Even without treatment. so her brief list of symptoms and personal preferences led to a trial on medication. for example) might put that individual at increased risk for depression later in life. what treatments have previously helped. the severity of the symptoms. due to side effects or previous lack of effectiveness. dislike of medication. For mild to moderate depressions. too. Balancing effectiveness against side-effect profiles. bupropion (Wellbutrin). and the patient’s preferences (for example. the best first choice for a mild to moderate depression is usually venlafaxine (Effexor). doubled it after a week when she felt no improvement. Alcoholism and the misuse of other substances are also highly comorbid. a maintenance phase. many of these hypotheses are compatible with other theories—for example. either psychotherapy such as CBT or medication can be effective. Depression as Learned Response. Repeated failure in childhood to master skills (mathematics or a musical instrument. As with most drugs. for many people. or “too busy” for psychotherapy). especially panic and other anxiety disorders often occur in patients with major depression. In all likelihood. and. Suzanne had to depend on others for transportation. The cognitive model has inspired innovative psychotherapy. Suzanne started the SSRI citalopram (Celexa) at 20 mg/day. citing anything bad that happens as proof of their own incompetence. a lot of damage could be done if depressed people just waited for their symptoms to subside. loss of a parent or other harsh environmental factors) to react negatively to stress. During an episode of depression. We think of treatment in terms of three phases—an acute phase (the first few symptomatic days or weeks). Of course. depressive disease tends to linger for months and then melt away. or one of the SSRIs. Depression that on its surface can appear no different from major depressive disorder occurs with somatization disorder. Somewhat related is the cognitive theory of depression. such as cognitive-behavioral therapy (CBT) and its variants.Depression 38 depressed person has a tendency (perhaps genetic. directed at major depressive and other disorders.

Severity. and it may also be less likely to precipitate mania. consider venlafaxine or mirtazapine. To treat more severe depressions. psychotherapeutic interventions such as CBT and interpersonal psychotherapy can be as effective as medication. avoid SSRIs and consider more sedating drugs. one person might be tempted to relieve depressive thoughts by the high that comes with a marriage proposal or having a baby. and that their decisions could look quite different once the depression has lifted. sedation. such as mirtazapine (Remeron). and the more a clinician worries that things could worsen rapidly. Generally. too expensive. people seen frequently in psychotherapy have more chances to ask questions and have their doubts addressed. because you don’t know how effective any treatment will be until you try it. For someone who must take a lot of other medications. CHOOSING TREATMENT Here are some factors to consider when choosing a treatment for depression: Target symptoms. and too unsure to use as the main treatment for depression. which makes it more likely they’ll follow their therapy regimens carefully and remain in treatment. whether as a symptom of depression or as a side effect of another antidepressant. Third. For example. patients should be cautioned against making any big decisions or major life changes when depressed. several weeks on the usual therapeutic dose of any drug is needed to assure that the trial has been adequate. the worse the symptoms. Someone who is troubled by sexual dysfunction. another might seek distance from a spouse through divorce or separation. the more troubled the patient. once treatment begins. Whether or not formal psychotherapy is used. After a couple of weeks or so. or severe risk of suicide). sexual dysfunction. and the psychotherapies have almost none at all. using two approaches hedges your bets. which have fewer side effects and drug-drug interactions. Bright light therapy has few side effects. Patients should understand that big decisions can have big consequences. For atypical symptoms. Psychoanalysis and psychoanalytic psychotherapy are too slow. or anticholinergic effects such as dry mouth and constipation. might do better with nefazodone or mirtazapine. also consider combining medication with CBT. SSRIs or MAOIs may work well. nefazodone (Serzone). which have few interactions with other drugs. They do this for several reasons. Side effects and interactions. These are the problems that most need to be addressed.Depression 39 start low and increase slowly to minimize side effects. such as excessive sleepiness and increased appetite. reassess the situation with the patient: Is a response beginning? What is the extent of side effects? These questions help determine whether to increase the dose or try a different medication. In mild to moderate major depressions. or a TCA like Elavil. In most cases. For a really severe depression (symptoms of psychosis. profound weight loss. And for the more severe forms of the illness. A two-pronged approach has a better chance of arresting a downward spiral. you might want to go straight to hospitalization and ECT. If the patient is agitated or has insomnia. For a mild or moderate depression. Second. . Bupropion doesn’t usually cause weight gain. consider one of the specific psychotherapies or a newer medication such as citalopram or (sertraline) (Zoloft). medication or other somatic treatment is almost always indicated. A more severely depressed patient may respond better to a TCA or venlafaxine. First. many clinicians combine medication with psychotherapy. Symptoms that appear regularly each fall or winter suggest bright light therapy as a first course of action. this will require from 3 to 6 weeks.

For depression plus an anxiety disorder. they could be getting worse. A year later. it is important to be seen at intervals. To guard against relapse. once sleep disturbance or poor concentration begins to recede. improvement is on its way. after initial improvement. For patients who start to lose ground. Maintenance phase If all goes well. then gradually reduced it to zero. you should probably not change anything. it is vital to impress upon the patient that. including medications and side effects. How frequent should your psychotherapy visits need to be? If someone else provides psychotherapy. for the half year or longer of the maintenance treatment phase. Relatives who know about the illness. Because past behavior is the best predictor of future behavior. then X is a reasonable starting point for treating a subsequent episode. Compliance. or other social problem could necessitate referral for social support. Biopsychosocial. legal. first address that problem. off medicine. illness of friends.Depression 40 Associated diagnoses. During the maintenance phase. a first step would probably be something as simple as a small increase in medication—this worked for over half the patients in one study who. • Assess side effects of treatment. For example. Patients who have had trouble complying with treatment should be seen weekly and closely questioned about what medications they are taking. For a depressed person who also has another psychiatric disorder (such as obsessive-compulsive disorder or bulimia). Previous episodes. even if doing well. treating the other disorder may address the depression. to side effects). the patient should return for a second visit within a week or two. and many other stressful events can complicate the life of someone who is battling depression. if a previous episode of depression responded well to a treatment X. Suzanne took her medicine for another 6 months. this referral could prove to be a vital part of the treatment process. can help assess progress and watch for evidence of relapse. Family problems. For someone who misuses substances. and how often. all clinicians should communicate frequently. which would also attract your attention. marital discord. How bothersome are any that have appeared—enough to require a dose adjustment? A trial on something different? • Address the effects of stressors. she was feeling well—and had even learned to drive on the freeway. FOLLOWING UP TREATMENT For most depressions. There’s almost always some of that. some patients will report a sudden change—for the better—in how they feel (“It was like someone threw a switch”). you’ll need to: • Obtain any additional information that was overlooked on the first interview. Of course. For these patients (and their families). Although some patients need only one or two legs of the classic mental health treatment three-legged stool—the biopsychosocial approach to healthcare—remember that a job. At that and subsequent visits. changing medications or starting psychotherapy may prove effective. consider paroxetine (Paxil) or sertraline but not bupropion. they “knew” that . • Plan for future visits. If this is ineffective or impractical (due. too. housing. From that moment on. had become symptomatic again. • Ask about changes in target symptoms. In any case. • Provide family education and support. perhaps.

” “I can’t imagine feeling the way you do. and it won’t change the way I feel about you. for most patients.” “If you had to have a mental disorder. With this experience. even helpful.” What patients might need to hear On the other hand. I’ll still care.” “Just snap out of it.Depression 41 they were no longer ill. they’ll probably be mild and manageable. and (2) it minimizes discontinuation side effects that are so common with psychotropic medications. after 9 months or so you’ll need to begin a medication taper to see whether they can get by with a smaller amount.” “What you need is a [job] [romance] [new car] [hobby]. especially from a loved one.” “I know you can’t help the way you feel.” . We’ll discuss them later (page 45).” “You are so important in my life. they can stop treatment. but I can feel how much you are hurting. whatever one says should be heartfelt. you could pull yourself out of it. or impossible. The physician’s approach to the patient What not to say There are dozens of things a depressed person doesn’t want to hear.” “It’s OK to [cry] [be depressed] [feel angry].” “Call me anytime—I’ll respond.” “Everyone feels down once in a while.” “Go shopping. here are some sentiments a depressed person might find entirely appropriate. That always helps me when I feel down.” “I’ll see this through with you. because they seem unbelievable. “I’ve known dozens of people who’ve had depression. we’ll still be together. insincere.” “I love you.” And you might advise the family to try: “Your doctor says that you’ll get over this and be well. However. Tapering has two advantages: (1) If symptoms reappear.” “I know just how you feel—I have a bad day now and then myself. And I believe your doctor. you picked the right one. and no one should make promises they cannot keep. Of course. Here are some of the more common statements that relatives (and sometimes physicians) make that don’t work well: “Nobody promised life would be fair.” “When we get through this. Prevention Preventing future episodes is especially relevant for patients who have repeated episodes of depression.” “If you’d just try.” “You have so much to be thankful for.” “Depression. and they got well. Such statements are often made by caring people who have no conception of what a depressed patient is going through.” “Lots of people have worse problems than you do. happiness—it’s all choices you make.

and if they didn’t arrange themselves. following her son’s divorce Alice began to blame herself. psychotherapy and social supports—the classic biopsychosocial approach to psychiatric management. Treating atypical depression As with other types of major depressive disorder. I guess”) that she’d gained about 10 pounds.Depression 42 Atypical Depression In the type of major depression called atypical. even untreated. so she was offered medication. “I’d plop the flowers into a glass of water. Despite her lack of appetite. Alice had recently thought about driving her car off the mountainside road near her home. so she wasn’t psychotic) and thoughts about driving off a cliff. For more than a month now. Even when they aren’t depressed. she felt constantly tired and listless. If something good happens. Symptoms of atypical depression Here are the symptoms that differentiate typical from atypical depressions: • • • • • The typical depressed patient has a poor appetite and loses weight.” Her own divorce several years earlier had been “all my fault. as if weights were tied to them. that was just too bad. Though she slept an extra hour or two each night. but Alice slept more than usual. she didn’t function well there.” she said. Some patients with atypical symptoms also notice that their extremities feel heavy. Although everyone always called her the ideal mother-in-law. depressed people typically don’t feel much better. certain symptoms (especially appetite and sleep) are different from the classical picture. Two of Alice’s depressive symptoms were alarming: increasing feelings of guilt (she recognized that these were exaggerated. Alice felt almost normal. dropped in. and she wondered how long it would be before she was let go. but Alice ate so much that she gained weight. but I wear contacts. Marge. she perked up and felt “almost normal” whenever her best friend. she had felt “all fuzzy” most of the time. Depressed teenagers and young adults often have hypersomnia. “like I needed to clean off my glasses. However. The typical depressed patient complains of insomnia. Although she still went to work. but in Marge’s company. These symptoms spelled a moderately severe depression. . atypical depression responds rapidly to appropriate therapy.” She told her doctor that she felt worthless and had accomplished nothing with her life. they eventually remit. She brooded that she had spent too much time worrying about herself and not enough time making her son’s wife feel welcome in the family. she felt steadily worse as evening drew near. She spent much of her time crying or accusing herself of being “a terrible mom.” Alice had begun to neglect her two teenaged children and “couldn’t care less” about her job as a florist’s assistant. Each day. these people may be unusually sensitive to rejection. she was eating so much (“Filling up the void. She had used all of her sick leave.

(Had that not worked out. Joyce. When he did talk. When asked whether he planned to use his shotgun on himself. and she looked on in dismay as he buckled his belt a couple of notches smaller.Depression Alice was immediately referred to a psychologist to begin CBT. But Brian insists we’re povertystricken. Psychotic Depression About 15% of people with major depression lose touch with reality. partly because they often work well. Although he complained of feeling tired all the time. he would say he was worried about being in debt.” As time passed.” When Brian brought out the shotgun. worked quickly when she found him cleaning the shotgun he hadn’t picked up in years. For a 2-week washout period she took no medicine at all. Joyce couldn’t even get him to eat his favorite foods. Her doctor started her on 20 mg/day of the SSRI sertraline. and there’s my paycheck. By this time. We own the farm. “Of course.” he would mutter on his way outdoors. she had improved a little. Brian’s wife. pace around the room. Joyce called the doctor. that his heart would stop. he would awaken at 2 or 3 in the morning. Nearly 3 months earlier. Brian’s mood had darkened and the chores on his almond farm seemed a burden. still stalled at “slightly improved. family services should be involved. Joyce had been trying unsuccessfully to persuade her 55year-old husband to see a therapist. However.) A month later Alice cheerfully reported that she felt “lots better” and was back at work arranging flowers. When Joyce was awakened by his tossing and turning and asked what was wrong. Until her mood disorder improved. so a social worker was asked to explore the possibility that her husband might take the children for a few weeks. These obviously psychotic symptoms seem all too real to these patients. Then she began the monoamine oxidase inhibitor (MAOI) phenelzine (Nardil). They may imagine they hear the voices of dead people or become deluded that they have died or are being persecuted. it is usual to try one of the SSRIs first. he was barely moving and speaking so slowly that it could take minutes to convey a single thought. For weeks. After 2 weeks. do whatever he could to keep his heart going. Two weeks later. but it made no difference.” she stopped sertraline. he apologized for all the pain he had caused—Joyce had no idea what he was referring to. lie down. He thought he was going to have a stroke. so it was increased to 40 mg. put his feet up above his head. who admitted him to a closed psychiatric ward. she needed help with child care. partly because clinicians like to avoid the worry of a low tyramine diet. we always have a few hundred dollars on our VISA card. through her county health department or perhaps a religious organization. with instructions to follow the special diet carefully. Immediate action may be necessary to prevent destructive behaviors. that we’ll have to sell out. feel his pulse. the MAOIs often work better in atypical depressions than do some of the other antidepressants.” Joyce later explained. 43 As in the case of Alice. The ongoing CBT helped her through the transition. who sometimes react impulsively to them. Mornings were worst—”Another damn day to get through. including suicide. He’d ask to have his blood pressure taken several times an hour. Marge might also be a resource. Brian spoke less and less. Joyce described how he’d get up. “but we pay it off every month. Then he began to ruminate about his health. “I pointed out that he’d had a checkup last month. he slowly nodded his head. .

he had become suicidal and evidently had a plan. Despite good physical and financial health. with even the possibility of brief commitment. office visits as frequently as several times a week and interspersed with telephone calls. Most patients recover completely between episodes. Once recognized. his activity level was severely slowed. the side effects and toxicity of TCAs make them more dangerous. That was what Brian’s doctor recommended for him. For a severe depression. such as an SSRI. though they are often severe (profound guilt. The antidepressant will usually also be a newer one. By the time he was admitted. In such a case. However. Many patients with a severe depression respond best to electroconvulsive therapy (ECT). sometimes recurring for many years. Brian’s basic depressive symptoms included loss of pleasure in his usual activities and undeserved feelings of guilt. If hospitalization isn’t feasible. the safest place to be treated may be on an inpatient unit—anyone whose depression involves delusions or hallucinations is too unpredictable to be safely kept at home. or other especially grave symptoms should prompt a full psychiatric evaluation. Patients with psychotic depression often receive a combination of an antidepressant plus one of the newer antipsychotic medications such as olanzapine. marked loss of weight.Depression 44 Symptoms and diagnosis of psychotic depression The symptoms of psychotic depression are drawn from the same list as any other DSM-IV depression. three weeks later. suicidal ideas). the problem of multiple depressive episodes is usually managed readily Symptoms and diagnosis of recurrent depression This will be quick. but their number and intensity are more severe. until safety can be assured. severe guilt feelings. . patient and family alike should be carefully apprised of the risks. he went home. He felt worst in the morning. The list of symptoms is the same as for any other episode of major depressive disorder. However. Recurrent Depression About a third of patients with major depressive disorder will have just one episode—that’s plenty. His delusions were striking. especially if there’s a plan and a means ready to hand. the rest will have repeated episodes. caring adults. may serve as a (risky) substitute. with its twin advantages of high effectiveness (about 80% respond well) and zero chance of a suicidal overdose. but TCAs sometimes work better. even if accompanied around the clock by watchful. they will assure you. especially for a patient who is psychotic or suicidal. Suicidal ideas also suggest hospitalization. Suicide plans. and he slept poorly and experienced profound loss of appetite and weight. recovered. Treating psychotic depression Depressive delusions and hallucinations are not some separate disease but symptoms that require special treatment. he remained convinced that he was poverty-stricken and about to have a stroke or heart attack.

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Preventing recurrent depression
Treatment of an individual episode of recurrent depression is as for any depressive episode (p 38). Then consideration turns to prevention of future episodes, using medications or specific psychotherapy such as CBT. The following factors can help you decide whether to recommend protection against further episodes. • • • • • • The symptoms were especially severe, e.g. psychosis or suicidal ideas. There have been multiple episodes. Two or more previous episodes predict greater likelihood of future ones. Episodes occur every 2–3 years, sometimes even more often. Without prophylaxis, such patients sometimes spend nearly half their lives fighting depression. The episodes are especially long-lasting or difficult to control. The person’s life was badly disrupted—divorce, job loss, self-injury can result from even moderately severe depressions. There is a family history of bipolar disorder, which suggests risk for future episodes of both mania and depression.

Prophylactic treatment often means continuing the same treatment that was effective in the first place. If the treatment is psychotherapy, it could be gradually reduced in frequency, perhaps to once every 3–4 weeks. If medication, it should probably be continued at the same dose (lower doses will often allow breakthrough depression), though clinician appointments can usually be reduced as low as every 2–3 months. A family history of bipolar disease would encourage the use of a mood stabilizer such as divalproex or lithium. A pregnant patient who previously had a postpartum depression might want to start psychotherapy at once or take medication after she delivers. Even with long-term protection, some patients experience breakthrough symptoms. Then, you’ll need to increase the frequency or dose of the current therapy. Sometimes, it is necessary to take further measures yet, as discussed under treatment-resistant depression (below). With the patient’s consent, fully inform family and close friends about the mood disorder and the symptoms of recurrence to watch for. Some patients don’t realize when they are becoming ill; their close associates are often in a better position to recognize the recurrent symptoms. Such an “early warning network” of family and friends can help ensure the ready availability of treatment. Many patients ask, “Will I need treatment forever?” A good answer is that forever is a long time, and most depressions don’t require treatment nearly that long. Patients who have had frequent or severe recurrences will probably agree that long-term treatment is a breeze compared to the whirlwind of endlessly recurring depressive disease. For those who elect to discontinue maintenance therapy, taper them off treatment slowly enough that any symptoms of returning depression can be caught and remedied before they become disabling.

Dysthymic Disorder
People with dysthymic disorder (often shortened to dysthymia) feel depressed most of the time, but their symptoms are fewer and milder than in major depression. They are neither psychotic nor suicidal, but their mood is nevertheless low enough to cause interpersonal or work-related problems. Many people feel this way chronically, perhaps since adolescence (“I’ve always been

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depressed”). They can go for years without realizing that persistent low mood isn’t normal, and seek help only when, as often happens, they finally develop a major depression. Once the major depression departs, they usually return to their “normal” dysthymia—unless it is recognized and treated. Despite his years-long marriage to Carol, Ira admitted that he had always felt lonely and isolated. “I’ve never been self-confident, but she sure hasn’t helped matters any. According to her, I’ve never done anything right with the kids—couldn’t even change a diaper properly. It seemed easier just not to be involved.” He had always felt inferior to others; any form of rejection could devastate him for days. Carol added that he was reluctant to make decisions and that he always complained of feeling tired. His sleep and appetite had always been adequate and he never had suicidal ideas. “I’ve never been worse, but I’ve never been much better, either. It didn’t even make much difference when I won ten grand in the lottery.” He discovered his dysthymia when they sought marriage counseling. “I knew he was a quiet, private sort of person, even before we got married,” Carol explained. “But he won’t even go on vacations with us. Most of the time, I feel like a single parent.”

Symptoms and diagnosis of dysthymia
Because the symptoms of dysthymia can seem to merge with a person’s character structure, recognizing it may be a problem—Ira’s symptoms seemed normal to him. Ira’s low self-esteem, difficulty making decisions, and gloomy demeanor are typical depressive symptoms, but he had too few of them for major depressive disorder. Also, they had lasted far longer than most major depressions. Without marriage counseling, he might never have been evaluated or received appropriate treatment. Major depressive disorder superimposed on dysthymia is sometimes called “double depression.”

Treating dysthymia
Dysthymia patients are often started on an SSRI. If that proves ineffective, a rational next choice would be just about any other antidepressant, including MAOIs. As with major depression, specific psychotherapy (CBT or interpersonal psychotherapy) can often either supplement or replace medication. Prolonged treatment may be needed to preserve improvement in this often chronic condition. Regardless of the specific treatment, unlooked-for consequences can occur. Successful treatment can change the way people feel about themselves. Within 2 weeks, Ira had improved to the point that he tried to take charge of all the family decisions. It quickly became apparent that he needed psychological help in adjusting to his newfound confidence. He and Carol continued their couple therapy, which eventually helped the family learn to live in a relationship where no one was depressed, passive, or dependent. As depressions go, dysthymia isn’t dramatic. Perhaps that explains why it often goes unrecognized and undertreated, despite affecting about 3% of adults.

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Depression Due to Medical Illness or Substance Use
Many medical conditions can cause symptoms similar to major depression. These include such common disorders as thyroid disease, menopause, migraine, premenstrual syndrome, sleep apnea, and stroke. Depression occurs in Sjögren’s, where it frequently begins before the typical physical symptoms of the syndrome. Some verge on the exotic—tick-borne Lyme disease, for example. It is unusual for these conditions to cause depression, and that’s exactly what makes them dangerous—if they routinely produced depression, we’d consider them first with every patient we see. Unhappily, often it’s only when antidepressants and psychotherapy don’t work or when more obvious symptoms of the medical condition appear that we twig the correct diagnosis. On the other hand, depression due to substance abuse is probably a lot more common than most people realize. Alcohol-related disease may cause more depression than all other drugs combined, but barbiturates, cocaine, heroin, or even nicotine withdrawal is occasionally the culprit. Most depressions caused by medical disease or by substance use don’t need specific treatment, but they do require special care with diagnosis. That’s why physicians must ask questions to dredge up all the facts about their patient’s social and medical backgrounds; something as covert as closet drinking or as small as a tick bite could provide the clue to the right diagnosis. Post-partum depression A special kind of medically related depression develops in 10– 15% of women within a few months of giving birth. The symptoms, often indistinguishable from major depression, appear related to rapidly falling hormone levels that occur after the expulsion of the placenta. Estrogens, taken either orally or by transdermal patch, can sometimes relieve depressive symptoms, but also pursue standard antidepressant measures. Don’t confuse this depressive syndrome with the milder—and far more common—“baby blues,” which develops within the first few days after giving birth and remits spontaneously within a week or 10 days.

Situational Depression and Adjustment Disorder
Is depression ever normal? Of course, it seems natural to feel sad about any bad outcome—a promotion lost or a romance gone awry. As the months drag by, someone who has lost a job and can’t find another might feel increasingly dejected; it’s a frightening and lonely feeling not to be able to provide for your family. After 6 months of rejection, you might feel unable to go on pounding the pavement, looking for work. Here’s the sort of situation that’s ready-made for the term Adjustment Disorder with Depressive Features—in effect, a depression that’s sort of normal. Adjustment disorders (including subtypes with various features—depression, anxiety, mixed anxiety and depression, disturbed conduct, mixed disturbance of emotions and conduct, and unspecified) are diagnosed so commonly they constituted up to 10–30% of mental health outpatient clinic populations. They occur at all ages, but adult women may be twice as likely as men to be so diagnosed. One problem with the concept is that very few really well-diagnosed patient cohorts have been followed up to determine whether this diagnosis was warranted in the first place. The line between clinical and “understandable” depression isn’t always clear-cut. Although we might think that the sole cause of such a depression was job loss, we could discover that the

who seemed a little sadder than usual. on the other hand. It really seemed like it was going to help. I felt so much better. I’m back to the way I used to feel. A few weeks later. and the same might be said for someone who is being seen in psychotherapy too infrequently or by the wrong therapist. Acute grief runs its course as those left behind adapt to their new circumstances and resume normal life. “and my GP started me on Prozac. No medication can work well on a dose too small. For several months. The trouble for clinicians lies in discriminating cause from coincidence during the episode. And he’s been fine ever since. he began treatment with a clinician who first tried antidepressants. Certain of the criteria make adjustment disorder a fraught concept. sometimes assisted by friends or groups such as the AARP Widowed Persons Service. A few years back I ran into Jon. It all comes down to this: Adjustment disorder is a nonspecific diagnosis that hasn’t been especially well studied for which there isn’t any specific treatment—other than allowing time to pass.” Now. It is a type of depression (or anxiety disorder) that should be placed pretty close to the bottom of anyone’s differential diagnosis. Bereavement Here is another syndrome that fits into the general area of depression due to an external event. but he must weigh twice what I do. Most people who have suffered the death of someone they love feel terribly sad. Jon’s about my height. Earl had been treated for depression. biochemical factors would seem implicated. “It’s stopped working. . it’s just one that treatment appears not to alleviate.” he said. Only about a third develop many symptoms of major depression. you can’t have confidence in the diagnosis until the cause departs and the depression retreats. but not all “resistant” depressions yield so readily. too. but the majority never require mental health treatment. His partners in an accountancy firm had voted him out for erratic behavior. because the two biggest causes of treatment resistance have nothing to do with the effectiveness of medication or psychotherapy. so I told him that 10 mg seemed a modest dose for any adult. If depression lasts past 2–3 months. Most “resistance” is caused by treatment that either is inadequate or is prescribed for the wrong diagnosis. Appears. Treatment-resistant Depression “Treatment-resistant” doesn’t mean a distinct type of depression. Jon’s situation was easily diagnosed in a few minutes of casual conversation. Jon was getting the right medicine but at the wrong dose—his doctor was too cautious by half. Jon had doubled the dose and was feeling great. there must be an evident cause. Nothing worked. On the one hand. suggesting that genetics accounted for part of the cause. When an antidepressant provided effective treatment. After he and his wife separated. “I finally went to see about my mood. a friend of many years. then a mood stabilizer.Depression 48 patient’s parent had repeatedly been hospitalized for depression. maybe he should ask his doctor about taking more. most clinicians would then treat for major depression. though I’m still taking the same dose—10 mg. perhaps emphasizing a specific psychotherapy such as CBT.” “Why is that a problem?” I wanted to know.

Try an MAOI—they sometimes work when nothing else does. perhaps weekly sessions will work better.Depression A consultant reviewed his history for something his clinicians were missing. Individual metabolism or other factors may be reducing the effective amount of available medication. Several months. We sometimes think we understand why older people are depressed—they’ve experienced so many losses—and overlook a treatable depression. thyroid hormone. some patients who don’t respond well to one treatment may improve with another. “but could you make a house call?” When the consultant arrived. strongly consider one of these modalities. If the patient isn’t using CBT or interpersonal psychotherapy. An antidepressant plus lithium is one of the most effective combinations. many patients with well-diagnosed depression respond poorly to the usual treatments. Still. an increased dose of the same medication may be the best next step. Add psychotherapy. For a depressed older patient. he was sober and no longer depressed. if a patient hasn’t done well on the first drug of choice. Earl was lying on his bed. such as the TCAs. or a central nervous system stimulant such as dextroamphetamine. and because each human being has individual chemical makeup and metabolism. Has treatment been given long enough? Antidepressants can require 6–8 weeks for full effect. you can augment an antidepressant that has helped some by adding another drug. You could also combine nortriptyline or desipramine with an SSRI such as citalopram. If psychotherapy every 2 weeks isn’t helping. Although professional opinions vary. a change to a drug in a different class of antidepressants may be the next logical step. Similar stories can be told about patients with other diagnoses. or change its focus or type. • • • • • • • Beyond this point. Then one evening his wife called and said that he was sounding very depressed. Consider ECT. and came up dry. and possibly safer. resistant depressions usually get treated with increasingly complicated drug combinations. Because clinical depression comprises a number of illnesses. 49 Drugs and other physical methods of treatment are just plain wrong for some depressions. Blood level checks can sometimes help with certain classes of medication. Earl’s “treatment resistance” was due to a mistaken diagnosis that directed his clinicians’ attention away from management of his drinking problem. than repeatedly stopping and starting antidepressants. especially if there are few side effects. Clearly. including eating and personality disorders. For example. . increase its frequency. consider psychotherapy or smaller doses of standard medications. For them. it remains the most effective treatment option we have for severe depression. it seemed intended for Earl himself. Other drugs you can add include another mood stabilizer. Though the gun was pointed at the consultant. some disulfiram (Antabuse) and a generous helping of Alcoholics Anonymous later. but 2–3 weeks should produce a glimmer of change.” she said. A month on a normally adequate dose with no change at all probably means its time to try a different antidepressant. he had been less than candid about his drinking. Although some people hate the thought. consider these points: • Is the dose high enough? If several weeks have yielded little or no effect from an antidepressant. a strategy far more efficient. “I know it’s unusual any more. propped up on pillows with a bottle of whiskey in one hand and his 12-gauge shotgun in the other.

” From the available information. nearly lifeless. He had smoked all his adult life. No one had heard much from Jay until he was brought to the emergency department after he attempted suicide by carbon monoxide poisoning. and those that pertain to the individual. feeling worse in the mornings. He said that when he awakened about 3 or 4 each morning. Although suicide and suicide attempts are not tied to any one diagnosis. That evening about 10. He had been discovered unconscious in his garage when a neighbor returned home unexpectedly at lunchtime and heard the purring of an engine. Jay went into the toilet and closed the door. his wife had died. he would lie there and brood about the death of a friend with whom he served in Vietnam. “I could have picked up that grenade and heaved it. in his late 60s. Risk of suicide increases with more severe depression and with the presence of melancholic features (loss of pleasure in usual activities. but he still kept two rifles and a pistol locked in a cabinet.” He had lost his interest in hunting. They’d been childless. he said that if he learned he had cancer. but now he mostly just sat at home. or “just do the job myself. There are two basic sets of risk factors for suicide: those that pertain to mental illness. They found him. Jay’s physician felt that there was an extremely high risk of further suicide attempts and placed him on a one-to-one suicide watch. Not a religious man. each of the following is associated with suicide behaviors. Jay was sallow and gaunt. though his father had died a horrible. Mental disorders and suicide Like Jay. he wouldn’t have it treated. Five minutes later. For a time he’d worked in his brother’s machine shop. a doctor had recently told him that a spot on his lung was “suspicious. the aide attending him called out. Jay would either move to Oregon and request physician-assisted suicide.” and that he needed to come in for more tests. His clothes hung on his 6-foot frame—he had lost 20 pounds or more. and the staff broke down the door. he lived alone on his military pension and Social Security. mostly because patients haven’t been treated adequately for depression.Depression 50 Sidebar: Suicide and Mental Illness The low base rate of suicide (about 1% of the general population) and the inexact nature of the science make it hard to predict which individuals will attempt suicide and which will succeed. who learned that he had been drinking heavily to combat a severe melancholia. Jay had retired after 30 years of honorable service in the Marine Corps. insomnia typified by awakening too early in the . and he had never been a particularly social person. Now. Mood disorders. hanging from a loop of bath towel and cut him down. Major depression and bipolar disorders account for about half of all suicides. Jay recovered enough to speak with a mental health consultant. the vast majority of those who attempt or complete suicide have a diagnosable mental illness. We have to rely on the seemingly numberless studies that try to pinpoint characteristics of suicide risk. in the comfort of my own living room. After several touch-and-go hours in intensive care. but I just jumped behind some sandbags. A couple of years earlier. lingering death from lung cancer.

excessive guilt. and lower in those with negative symptoms (flat affect. Isolation often breeds despair. Risk is higher in those with paranoia or depressive symptoms. loss of appetite or weight. I believe that these people also carry an increased risk for completed suicide. and a quality of mood that is more profound that typical grief). loss of a close relationship through divorce. In a person who has made previous attempts. Unemployed and retired persons. Living alone. There is even a risk with panic disorder. Physical disease. The risk of suicide is especially great in antisocial and borderline personality disorders. separation. Being single or divorced is a risk factor (divorced is worse). or interpersonal friction is a common precipitant. epilepsy. An unrelieved gloomy view of the future especially predicts future suicide. usually in the first few years of illness. Risk for Muslims is unclear. For patients with alcoholism. recent and heavy drinking increases the risk further still. The risk for Protestants is higher than that for Catholics and Jews. even beyond the presence of mental disorder. Patients with somatization disorder often attempt suicide. Whites are far more likely to commit suicide than are people of other races. and those with long absences from work. And please note that having more than one mental disorder greatly increases the risk of attempts and completed suicide. Personality disorder. . chronic pain. Illnesses as different as PTSD and attention deficit/hyperactivity disorder may also confer an increased risk for suicide. The first few days after discharge are the most dangerous. Access to guns and other lethal means. The burden of obstructive lung disease. Men are four times as likely as women to complete suicide. Individual factors in suicide For many years. Substance use. inability to initiate action).Depression 51 morning. numerous social and personal characteristics have been known to signal the risk of suicide: Male gender. About 10% of schizophrenia patients die by suicide. Employment. death. Advancing age. Feelings of hopelessness. may suffer from lower self-esteem and reduced access to support networks. Others. multiple illnesses greatly increase the risk. both of which may increase risk. married people are less likely to commit suicide. whereas women are three times as likely to attempt it. Patients with any type of substance dependence have a risk of suicide 2–3 times that of the general population (in those with heroin dependence. Suicide in a relative increases individual risk. Race. Recent studies have reported that in either depression or bipolar disorders. especially if major depressive disorder or substance use is also involved. poverty of speech. Family history. it is least 14 times greater). and a host of other debilitating conditions predisposes patients to suicide. cancer. although there are few data. Marital status. Suicide rates rise throughout the lifespan to peak in the over-85 group. Recent mental hospitalization. Schizophrenia. treatment with antidepressants or lithium decreases suicide risk. command auditory hallucinations increase risk for another. And don’t forget medications that can be lethal in overdose. Religion.

depression may mediate this factor.” He never had a lot of outside interests. over half by suicide. it is important to consider both medical and psychological seriousness. 4. 5. or states a determination to make another attempt. The death by suicide of a friend. Review Just out of college. “I suppose I should have gone out at gotten myself a higher status. Prior suicide attempt. 9% had died within 5 years. An attempt that entails either type of seriousness should put you especially on guard. of those who made a medically serious suicide attempt. The saying “Those who talk about it don’t do it” is exactly the opposite of fact: Most people who kill themselves have recently communicated their intent. his girl friend. better-paying job.Depression 52 Financial difficulty. rather lowspirited. He didn’t feel much pleasure. sleep had become a horror.” he complained to Francine. and he stopped participating in classroom discussions at the extension course he was taking in early American literature. 3. has made efforts to avoid discovery. which has been the case ever since high school. For weeks now he had barely managed to drag himself in to work. relative.” Carl admitted that he’d always felt unsure of himself. A medically serious attempt is one that causes unconsciousness. finally demanded that he seek a medical evaluation. Psychologically serious attempts are those in which the patient expresses regret at surviving. When evaluating an attempt. 1. “I always told myself. Pathological gambling as such may not predispose. Suicide of others. [p 33] Outline your suggested treatment approach for Carl. and it had always been hard for him to focus his attention. [p 38] . or disruption of parts of the body beneath the skin (tendons and arteries are examples). like my college roommates did. Francine. but as in just about everything else. risk for completion persists for at least four decades. [p 35] What would be your best diagnosis for Carl at the end of the first paragraph? [p 45] What important additional information about Carl do you need for a firm diagnosis? [p 33] Pick out Carl’s symptoms of a major depressive episode. Heavy gambling losses.”) His girl friend.” Carl reported. significant loss of blood. the rut had deepened. With frequent awakenings throughout the night. Carl had taken a job at a large chain bookstore in the city. In one study. “I’m in a terrible rut. but I just never felt that confident. “It’s just hopeless. I felt that I performed horribly. had become concerned at how much weight he had lost. for whom the pull of group behavior is especially powerful. The image of stock market investors leaping from windows during the Great Depression of the 1930s was no mirage: The national suicide rate surged by 20%. Talking about suicide. Write out a complete differential diagnosis for Carl.” By the time 5 years had passed and he’d worked his way up to assistant manager. 2. it was temporary. often to a care provider. even when he was having sex (“It was ok. “It’s normal for me—like being tired. or even a total stranger can increase the risk—especially in adolescents. to tell the truth. After an attempted suicide.

How might your treatment change if Carl spoke of being punished for his sins? [p 43] 8. in the midst of a psychotic postpartum depression. Review the history of Jay (p 50). It is beautifully written and contains enough detail that you can begin to understand how depression appears to sufferers. . If Carl had had an increased appetite and slept much longer than usual at night. Are You There Alone? is Suzanne O’Malley’s careful laying out of the Andrea Yates story. methodically drowned her five children in a tub of bathwater. how would this change your evaluation? [p 42] 7. She was subsequently found guilty of murder and barely escaped a sentence of death by a Texas court. Which risk factors for suicide did he have? [p 51 53 Further Learning A lot of memoirs discuss depressive disease and its consequences. I particularly like these two: The Bell Jar. Besides those I’ve listed in the next chapter. The details provide plenty of opportunity for discriminating types of psychosis. Yates is the Texas woman who. which mainly concern bipolar disorder. and schizophrenia from mood disorder.Depression 6. by Sylvia Plath.

her affect was buoyant and she often laughed and chatted. she looked downcast for a moment. a great family. and her speech included many unnecessary details that got her off track. Brie had never before been admitted to a hospital. bending down to remove her sock so she could show off her painted toenails and fresh tattoo. but then started talking again. she bought ten dozen Bic pens. At one point she said. “I’m delirious with joy. police were called to her place of work when two of her workers overheard her dialing numbers at random and asking unauthorized. She spent far more time working than her job (she served as office manager for a state-wide polling organization) nominally required. such as what kind of underwear people were wearing. As she was helped into the back seat of their cruiser. I don’t need much sleep. Just a couple of hours is plenty. recently she had begun to volunteer at an animal shelter. In fact. When she began screaming and threw several telephones at them. until the last 3 weeks her life had seemed ordinary. She was talkative and hard to interrupt. she noticed an empty soda can on the floor under the table. “Luckily. “So I went swimming in the fountain. they decided she needed evaluation and brought her to the psychiatric emergency room.Chapter 4 Mania and Mood Swings Brie danced into the interview room.” When a nurse restrained her from disrobing.” she said. Two days before she was admitted. At one point. she picked it up and began to speak about it. Brie maintained eye contact. When she refused to stop.” Brie had spent part of her extra time on shopping. a great body.” She swept a hand along the bulge of her side. “and I’m always losing mine.” One morning. “I’ve got to have one for work.” She stood up and began to remove her shirt to show how she had stripped to go swimming the day of her admission. she alighted in a chair and at once began to speak.” she volunteered. asking questions of several of the students. police were called. she was saying. With a pirouette and an attempted grand plié. “I just feel so lucky to have a great job. “You think I need evaluation? You must be nuts!” Throughout her interview. intimate questions. “And so I ended up 54 . “I’ve never felt better in my life. she arose to act out a part of her story. Several times. losing the thread of the previous conversation.

using drugs. but lecture. even minute to minute. sign contracts they can’t fulfill. For a patient with features of mania. However. Their actions—whether gambling. Mania patients talk a great deal. psych ward! [Looking around the room] Any other Wards here? My dad’s name was Edward. but first. Me. any of several diagnoses are possible. we feel good and want to laugh.” Increased activity level. mania patients don’t describe insomnia as a problem—why sleep when there is so much to be done? Inflated self-esteem. Brie had trouble sitting still. Typically. Though their activities are generally goal-directed. sometimes whether or not anyone is listening. which affects about 2 of every 100 adults.Mania on a psychiatry ward. not a diagnosis. or violating professional ethics. We’ll cover them later in this chapter. such as having sex with patients or spending money entrusted to them by clients—can endanger themselves and those around them. Brie impulsively bought pens she didn’t need and disrobed in public. and imbued with a “driven” quality that we call pressured speech.” 55 Symptoms of mania People whose mood is the opposite of depressed are said to have an episode of mania. (Brie started talking without prompting. during the course of full mania. I confess. Talkativeness. to qualify for a DSM-IV episode of mania. a cola can under a table—can divert the stream of thought into a different channel. as long as that person isn’t too high. someone may suddenly become quiet. For some patients. drinking. Edward the Confessor. They quarrel and argue with their friends and relatives. perhaps for hours on end. euphoric. a fly on a window sill. let’s identify the symptoms. describe their accomplishments in glowing terms. they can feel pretty uncomfortable when they are manic. often starting projects they will never finish.” a self-assessment typical of people in full manic flight. Brie’s comment about her “great body” suggests inordinate feelings of self-worth. Mania patients entertain so many thoughts that even rapid speech cannot keep up as they jump from one idea to another—a form of thought disorder called flight of ideas. I’m only Princess Di. often loud. including mood change. Faulty judgment. everything tends to be speeded up—they move fast and seem forever busy. Patients can become so difficult to interrupt that they don’t really converse. have sexual indiscretions. Reduced need for sleep. more severe stages. some mania patients aren’t so much euphoric as cross or irritable. or excessively joyful. During mania. Racing thoughts. Mood will usually appear to be “high”—excited.) Speech is rapid. subdued. Mania is a description. Hi. about nearly anything. In Brie’s story. Small diversions—noises in the hallway. other mania patients spend thousands they cannot afford. If only moderately elevated. and she was glad. Of the 8 core symptoms listed in boldface below. Distractibility. . the mood can be quite infectious: when we are around someone who is manic. we can identify the symptoms typical of classic mania. For a mania patient. even the mood of euphoria can have a perceived driven and unpleasant quality. even tearful for a few moments before once again “shifting into high. Brie slept less than usual. moods shift rapidly. Fairly bursting with energy. Brie’s last speech provides an example. it takes 4. Brie said she had “never felt better. people typically feel important and overconfident. In the later. and ignore their failings. and they can progress to downright hostility—especially if they are thwarted or feel threatened. they may be interested in everything and tend to make many plans. Mood.

if not remedied. manic themes are usually grandiose (such as being on a secret government mission or having a relationship to divinity). Grandiose delusions tend to be congruent to the exalted mood. gives way to pacing. after the period of mania subsides. patients with mania don’t recognize that they are ill or even how their mood has changed—but those around them do. impulsivity and faltering judgment yield chaos. Especially likely are sexual involvement. agitated hyperactivity. most express remorse for their former extravagant behavior. Perhaps a third of mania patients become psychotic—a higher percentage than patients who have only depressions. “How could I be sick?—I feel terrific!” They will refuse care and become angry. but they sometimes appear early. beginning with the more common ones. We’ll discuss each of the several psychiatric disorders that can present with symptoms of mania. A breadwinner whose family needs require two jobs gives away $10 bills on the street. a mother of 3 young children books passage for Argentina—one way. With worsening illness.” That’s the term clinicians use for patients like Brie who have at least one episode of full-blown mania and who fulfill a short list of other requirements: they have no substance use or apparent physical cause for mania. Usually.Mania 56 Typically. in extreme cases. death. and the illness is serious enough to impair . Although some patients become hostile and paranoid. (However. But the differential diagnosis places them. you can barely imagine the extent to which such symptoms can interfere with work (school) and produce financial turmoil. as usual. extreme cognitive disturbance can produce disorientation and confused behavior. Patients may believe that they have super powers (they can change the weather) or that they are in fact celebrities or religious figures such as Jesus. Ultimately.) If you haven’t experienced mania in a friend or relative. sometimes violent. catatonic symptoms will ensue (manic stupor). Rarely. As the illness escalates. The patient must also meet other conditions. can lead to collapse and. in effect responding with complete lack of insight. during the first week or two of illness. even fighting. you can’t make a diagnosis solely on the basis of the symptoms. purposeful at first. in a rough order on the safety hierarchy. psychotic symptoms begin as other mania symptoms escalate. Associations may loosen to the point of clang associations or word salad. Differential diagnosis As with any other psychiatric disorder. Mania due to substance use Mania due to a medical condition Bipolar I Bipolar II Cyclothymic disorder Schizoaffective disorder Schizophreniform disorder Normal? Bipolar I Disorder We used to call this more severe disorder “manic-depressive disease. When you try to enlighten such patients. outlined in Table 2 66. and problems in personal relationships. marital discord and divorce. lack of sleep may produce exhaustion that. they don’t believe you. if forced into treatment.” but most clinicians today use the term “bipolar I.

it tends to be seriously underdiagnosed. personal. The consequences of delay in treatment can be devastating in terms of anguish sustained. Genetics. Although there may be long periods of normal mood. Many studies find a high relative risk—about seven times that of the general population— in relatives. culture. during which they experience a combination of manic and depressive symptoms. clinicians often strongly suspect bipolar I disorder based solely on a typical course of illness—episodes of mania and depression with interspersed periods of normal mood. or economic status. suicide is a too-often tragic outcome. money spent. Men have a somewhat earlier onset than do women. Because its social consequences are often dire. It sometimes takes years to get the diagnosis right. Remarkably. Mistakes in diagnosis (many patients have been erroneously diagnosed with schizophrenia) probably occur less often now than they did half a century ago. . Even knowing nothing about an individual’s actual symptoms. a few patients will experience a first mania only after many years of repeated depressions. Course of illness Mania usually builds over a week or two (at least one week of symptoms is required for DSM-IV diagnosis). once depression supervenes. bipolar disorder occurs somewhat more often in females than in males—the ratio is about 3:2. the risk of eventually developing mania or hypomania is substantial enough that family and friends should watch for symptoms of mania (or recurrent depression). (2) Adoption studies find biological relatives are at greater risk for bipolar disorder than are adoptive relatives. nearly all manic patients will eventually have a depression. beginning in their late teens or early 20s and returning intermittently throughout life. Some bipolar patients have mixed states. or work functioning. Most such patients also have at least one lifetime major depressive episode. It is no respecter of race. An occasional patient has had only manias. Having a parent or sibling who has had mania increases the individual’s risk of bipolar disease to around 10%—far greater than for the general population. That holds for both bipolar I and II in first-degree relatives of bipolar patients. Though acutely manic patients rarely kill themselves. given enough time. Different studies of linkage have reported various putative chromosomal sites. For a depressed person who has a relative with mania. even with modern criteria and all the publicity bipolar disorders have received during the past 40 years. some patients are still misdiagnosed as having schizophrenia or some other psychosis. A strong genetic component to bipolar disorder is demonstrated by these facts: (1) Monozygotic twins of bipolar patients are about 60% concordant. but most of these studies have not been replicated. bipolar I patients have 8-10 lifetime episodes. though most clinicians will tell you that. When it begins in childhood. and even lives lost. dizygotic twins 7% concordant. without treatment patients with bipolar disorder tend to cycle up and down for many years. On average. However. it is almost never left to run its natural course—perhaps 3 months of symptoms before it spontaneously resolves into either a depression or a normal mood. Epidemiology and etiology Like depression.Mania 57 social. whose relatives also have an elevated risk of unipolar depression. Although the range is broad. on average it begins around age 25—even earlier than major depression.

Note that it is hard to know where to draw the line between pathology and a normal reaction to life’s vicissitudes. depending on gender of affected parent). Dopamine agonists (such as pramipexole. alcohol and other substance use can confuse the picture and even fool experienced clinicians. by mitochondrial inheritance. Anatomical structures. for many patients it remains the treatment of choice. hippocampus. It has been explained by imprinting (alleles are expressed differently. Stress may cause cortisol release in anyone. Of course. both of which are especially likely when onset of the mood disorder is relatively early. Divalproex (Depakote) works faster and has . Some investigators have reported that subcortical structures such as the amygdala. Maternal inheritance may be more common than paternal inheritance—the parent-of-origin effect. family history isn’t synonymous with heredity. trauma. 3-methoxy-4-hydroxyphenylglycol (MHPG) is lower in depressed bipolar than in depressed unipolar patients. bipolar patients with normal mood who continue to have insomnia may be at special risk for relapse. illness. getting married (or divorced). Other comorbid illnesses include eating disorders (both anorexia and bulimia nervosa) and anxiety disorders such as panic disorder and social phobia. Increased norepinephrine (NE) turnover has been reported in cortical and thalamic areas. by X-Linkage. For years we have assumed that mood disorders produced sleep disturbances. They may be trying to modify their own high moods—an acute mania is an uncomfortable mental state for many patients. and there is little evidence for precipitated mania. There are recent reports that low plasma tryptophan (precursor to serotonin) may cause unaffected relatives of bipolar patients to develop low mood and impulsivity. CSF NE and MHPG are higher during mania than during depression. or by intrauterine factors. Comorbidity In addition to the mood swings. the powerful mood stabilizer lithium was the standard treatment for acute mania. there’s lots of room for environmental influence. used to treat parkinsonism) not only have an antidepressant effect but in some bipolar patients have precipitated mania. Others may just be trying to enhance the high feeling. In any event. many bipolar patients also have other mental problems. but it takes root in soil prepared by heredity. plasma NE and its major metabolite. Treating mania For decades. and a host of others. These include events such as losing a job (or being hired). many mania patients do abuse alcohol. The increased hypothalamic-pituitary-adrenal axis activity reported during bipolar depression and mixed manic states has inconsistently been reported during mania. The most common comorbid condition is substance abuse. Although Brie didn’t drink. It is harder yet with mania. and striatum are affected differently in bipolar and major depressive patients. Sleep. Now. by the effect of being reared by a mother who is ill. some evidence suggests the opposite—that disrupted sleep can precipitate a manic episode. Further. Neurotransmitters. especially alcoholism. HPA axis. Here are some of the other factors that have been implicated in the expression of bipolar disorder: Psychosocial stressors. with a concordance rate less that 100%.Mania 58 The tendency to bipolar disorder is probably caused by genes at three or more loci that interact to cause the disease.

it isn’t enough. and serum drug level. There is also some evidence that stopping lithium for any reason can render it less effective when it is restarted. Beginning with fidelity to their treatment regimens. is optimal. but maintenance treatment for bipolar II (which we’ll define later) is also important. relapse is likely within six months of a manic episode. a different mood stabilizer such as lamotrigine (Lamictal) could be tried. patients can do much to prevent further episodes of either mania or depression. Continuing concurrent use of antipsychotic medication doesn’t appear to be generally helpful. For someone with relatively few episodes of mania with euphoric (but not irritable) mood. A patient who responds inadequately to lithium or other first-line treatment may need a concurrent mood stabilizer. About half of those with bipolar illness can be treated as outpatients. However. As with the acute management of mania. and no current substance abuse. who function poorly between episodes. A benzodiazepine such as clonazepam (Klonopin) or lorazepam (Ativan) may be added to manage the accompanying severe agitation. Bipolar I patients who don’t get effective treatment can lose months or years of normal life. and these drugs should be tapered as tolerated. Usually. Therefore. insomnia. lithium becomes more effective with continuing use. multiple episodes. Severe mania may require the addition of one of the newer antipsychotic medications such as olanzapine (Zyprexa)—this will be especially true if the mania is accompanied by psychosis. patients should be counseled to begin maintenance therapy immediately following a first manic episode. For some patients. or who abuse alcohol or street drugs. history of mood disorder in relatives. If any of those factors is present. lithium remains the treatment of choice. For a mixed episode. their potential for serious side effects has relegated them to a backup role. and dealing with stress. divalproex or carbamazepine may be a better choice.Mania 59 fewer side effects. If mania breaks through. however. Attending a mood disorders clinic every month or two can also help patients feel better about their illness and remind them of the problems they had when ill and help motivate them to stick with treatment. who cycle rapidly. mania doesn’t respond adequately to any medication. It is especially important to begin prophylactic medication early in the presence of rapid cycling. such as divalproex (Depakote) or carbamazepine (Tegretol). You may to add . Also important is teaching patient and relatives about watching for stress or signs of recurrence. taper off any antidepressants and check to see that the dose of maintenance medication. for others. Rarely. then ECT will often normalize mood. who also have a personality disorder. Preventing future episodes Without adequate prophylaxis. resistance to it develops after a time. For some patients. but the rest have manias that often require hospitalization to prevent harm coming to them and others. divalproex may work better than lithium. and panic. If that still doesn’t work. Although older antipsychotics like chlorpromazine (Thorazine) and haloperidol (Haldol) used to be popular. or episodes that are especially severe. Despite prophylaxis. complying with treatment recommendations. that will be simply the continuation of whatever mood stabilizer worked best for control of the acute episode. but overall lithium provides the greatest degree of improvement for the most patients. those who continue to have mood swings despite the foregoing measures can be helped with the newer mood stabilizing drugs such as lamotrigine. it is less effective for patients who have had many prior episodes. some patients will continue to have low-grade symptoms or breakthrough mood episodes.

talkative patient is an exercise in futility. The physician’s approach to the patient How best to approach the mania patient strongly depends on severity. For depressions that don’t respond adequately to the mood stabilizer. it is usually OK to laugh with. bipolar patients should try . if firmly. Try adding either a second mood stabilizer or thyroid hormone. is amenable to persuasion. friends (and sometimes the legal system) to present a united front. This strategy may work because of the storied brief attention span of mania—if you haven’t alienated the patient with previous confrontations. it is sometimes difficult to avoid. waiting a few minutes might just earn you another chance at promoting whatever attitude or action that was initially rejected. Indeed. try to interview with a colleague present. here are a few pointers: • Because they tend to speak loudly and at great length. Many antidepressants can precipitate an abrupt switch into mania. though of course never at. an antipsychotic. When an antidepressant is necessary. This might be most anything within reason the patient wants. mood stabilizers alone can produce a good antidepressant effect without risking a switch into mania. a patient who has had an episode of mania and is now depressed will need treatment that differs from a nevermanic depressed person. Dealing with more severely ill patients can be quite another matter. • If at all possible. inasmuch as these people are often (sometimes unintentionally) extremely funny. Soon after the depression lifts.Mania 60 another mood stabilizer. or a benzodiazepine. Place yourself near an exit (never with the patient between you and escape). and know how to activate your facility’s emergency call system. Treating bipolar depression Although bipolar depressions are similar to those of major depressive disorder. • Finally. bupropion (Wellbutrin) or an SSRI may minimize the risk of a switch to mania. augmentation sometimes works better than substitution. for some patients. It’s relatively easy to talk with a hypomanic person. perhaps you could answer just these two questions…” • When a patient simply refuses to cooperate. I’ve got to stick my oar in again” and so forth). divalproex. won’t shout at someone who is speaking ever more softly. perhaps a glass of water or speaking with a relative on the telephone. and whenever possible with humor. avoid confrontation. • Always consider safety—yours and the patient’s. Then. a mood stabilizer (lithium. Indeed. This should be done politely. reduce the volume of your own voice when you speak. • Try to find a lure to draw the patient into the treatment process. instead. a mania patient. Most people. “While we’re arranging that. The risk of a switch into a high phase is less for bipolar II than bipolar I patients. (“Sheesh. work with relatives. lamotrigine) should be in place when an antidepressant is prescribed for a bipolar patient. so they should never be used alone. It can work well to hold your amusement and let it out once the patient laughs or tells a joke. Even maintenance ECT might be needed in rare cases. and can often be thoroughly enjoyable to be around. even mania patients. who can converse more or less normally. you may need to interrupt repeatedly just to ask basic questions. or at least within earshot. • Responding loudly to a loud.

A patient with hypomania could have one of 3 different diagnoses: 1. increased appetite. others don’t think they are ill. This term means that the patient has had at least one major depression and at least one episode of hypomania. Outcome of bipolar mood disorder Once started on a mood stabilizer. Some feel they don’t need treatment between episodes. but others cycle more or less continuously. lacking even this support. the acute mania gradually disappears. Although rapid cycling often resolves spontaneously within a year. But at any given time. A combination of mood stabilizers may work when a single drug doesn’t. about a third of bipolar patients are not receiving the care they need. Their activity level is heightened but generally goal-directed and (often) quite productive. Lithium may not adequately stabilize these patients. become less and less likely to get competent mental health care. so they should be used with caution. in which case divalproex or lamotrigine may prove a good choice. their train of thought can be interrupted. about 20% cycle rapidly: in the course of a year they have four or more episodes of depression or mania—and some far exceed even this.” in other words. some bipolar patients fare poorly. The pattern can take the form of alternating highs and lows or repeated brief mania or depression. even during an acute episode. Although they may talk loudly (and a lot). or feeling worse in the evening. Rapid Cycling Although the average bipolar patient has fewer than a dozen lifetime episodes. even for one of those rare individuals whose moods swing up or down every 48 hours. . it can be hard to treat. but never an episode of mania. many patients remain well for years—as long as they continue taking medication. of course. Hypomania and Bipolar II The upward mood swings some people experience never progress farther than “moderate. to be replaced by chronic grandiose delusions. traditional antidepressants have been linked to rapid cycling or causing a switch into mania. Bipolar II disorder. But even with modern treatments and good compliance. the wakefulness-promoting drug modafinil (Provigil) has been reported to improve symptoms of bipolar depressed patients who have not responded well to more conventional therapy. and has the added benefit of not provoking mania. Although controlled evidence is lacking.Mania 61 to taper off the antidepressant medication—while faithfully remaining on the mood stabilizer. It is especially common among women and those who have had several previous bipolar episodes. Very recently. They retain insight that something is different or wrong. if at all. after a few months. CBT can be useful. Some patients recover for a time in between episodes. an episode of hypomania. They don’t have hallucinations or delusions or require hospitalization—either of these conditions would signal a full-blown mania. They become alienated from their families and. Rapid cycling is especially likely to respond if there are atypical symptoms such as sleeping too much.

3.Mania 62 2. but there may be a role for factors such as genetics and climate (heat and humidity in the tropics). If a major depressive episode develops and is treated. the pattern may be reversed.” Cyclothymic Disorder Here you would never have severe depression but would alternate between mild episodes of depression and hypomania. Instead. mood disorder assumes a peculiar pattern—they become depressed in the fall or winter. and she wrote poetry. Though their urgency is different. In tropical regions. cyclothymia is now recognized as a part of the bipolar spectrum of mood disorders. he had trouble maintaining .” Once regarded as a disorder of personality. Bipolar I disorder. Sal requested treatment for depression when he was a junior on a college athletic scholarship. returning to normal or even hypomanic in the spring or summer.M. her energy and enthusiasm allowed her to accomplish a great deal (“You can. when you get up at 4 A. such patients can sometimes evolve into bipolar I or II disorder. for the next several months. now that they no longer had to wonder “where Mom would be from one day to the next.”). Seasonal affective disorder (SAD. However. After a reclusive few months.” Her daughters said that they could relate to her better. She would go to (and give) parties. and sometimes develop relatively mild mixed states. her mood would brighten. The current episode is hypomania. For over 10 years. Because his appetite fell off. changing jobs. When her husband finally persuaded her to seek a mental health evaluation. the hypomanias of bipolar II and cyclothymic disorder are more common than bipolar I. Indeed. Seasonal Affective Disorder For some people. but in the past the patient has had at least one manic episode.” Later. “only now tinged with discipline. for a time she thought of herself as “productive but dull. even clinicians may not recognize the need for mood stabilization because the patient seems only to have “returned to normal. Every autumn for 3 years. she was quietly unhappy and lethargic and irritated her relatives.” she commented.” Once lithium had stabilized her moods. During her depressive phase. Rather than incapacitating high phases and typical major depression. “I never thought much about it. mania and hypomania are treated about the same. “I always assumed it was just the way I was. she discovered that her creativity was intact. Cyclothymic disorder. sometimes referred to as seasonal mood disorder) is somewhat more likely to occur in the far north. Taken together. We’ll cover that one below. she was astonished to learn that her condition was a disorder with a name. Holly had experienced mild mood swings once or twice a year. they react to mood swings by making changes in their lives such as moving. and falling in or out of love. because they are less severely ill. he had become depressed enough that his interest in school work and athletics waned. these patients chronically experience mild instability of mood. people with hypomania sometimes don’t bother seeking treatment. Their phases are continuous and may last weeks to months before switching into the opposite phase.

.000 lux). Moderate to severe winter depressions may require a combination of BLT with an SSRI antidepressant. not that he was the Bambino. Mood Swings Due to a Medical Disorder A variety of medical diseases can cause manic-like symptoms. BLT has been demonstrated effective for other conditions than SAD—including premenstrual depression. he played in every game. and improving sleep and reducing agitation in dementia patients. Although medications (especially the SSRIs) may help.” he told the doctor. He expressed the delusion that a deluge had submerged London. became depressed. He became so irritable and easily offended that his wife became alarmed and afraid of him. Some clinicians feel it can also work in depressed patients who do not have a seasonal pattern. Although he wasn’t incapacitated throughout the autumn. had trouble concentrating. so treatment should be started as soon as symptoms appear. or whatever. If the seasonal mood swings are especially severe. At times appearing depressed. and he lost weight. Often. he recovered spontaneously and remained well for the next 23 years. after 4 days. and often appeared worse in the evenings. He began to improve within a few days.400. King George experienced his first psychosis. Springtime hypomania is common. he became hyperactive and lost weight. reduced appetite. George slept little. The diagnosis of SAD has special implications for treatment. worrying about the next game. In the fall of that year he experienced severe abdominal pain and depression. his ideas jumping from one subject to another. it is the treatment to try first. Note that Sal wasn’t delusional—he said that he felt like Babe Ruth.” 63 Sal’s fall-winter depression symptoms included insomnia. he became high-spirited and agitated. he said he felt “like another Babe Ruth. suddenly. After a month or so. for relatively mild cases bright light therapy (BLT) can work just as well with little risk of side effects. This is what Sal did. loss of interest. “I might as well be setting an alarm. At other times. compared to the spring his performance was minor league.” When spring came around. but sometimes several weeks are required for it take effect. a mood stabilizer might be necessary to try to reduce the likelihood of future episodes. low mood. he swore at those who tried to restrain him and even physically fought them. or passing chemistry. and ruminations. Hours of nonstop talking left him hoarse. he also complained of insomnia. BLT often works quickly. For 90 minutes early each morning. When he was finally forced into medical care. he refused his medication and threw them away. George III. the bingeing in bulimia nervosa. he once begged his attendants to kill him.Mania his playing weight. When he was 27 years old. and after 10 days his interest in sports had returned and his sleep was normal. At times abusive. He spoke rapidly and at great length. he studied while he sat in front of a box that provided very bright light (10. He seemed to explode with enthusiasm when he went out for baseball. he ordered the royal yacht to rescue survivors. his speech was incoherent. Batting . At age 50. With loads of energy. and full summer remission is the rule. it was a different matter. He was so melancholic that for several weeks he complained of fatigue and insomnia. “My eyes click open and there I am. King of England during the American Revolution.

Substance-related Mood Swings A variety of substances can produce euphoria and other disturbances of mood. Huntington’s disease. any mood disorder patient should have a complete physical evaluation. they last only until the individual sobers up—an excellent demonstration of how important it is to pay attention to the longitudinal course of the patient’s history. George’s underlying condition was probably porphyria. Cushing’s syndrome. far beyond his bookstore job. working late one night. his girlfriend. . such as seasonality or distressing life events. and laboratory studies may identify other substance-related manic symptoms. Then. brain tumor. No Mental Disorder? Some critics believe that psychiatrists diagnose bipolar disorder too frequently and prescribe mood stabilizers too freely. treatment depends on the nature of the underlying disease. Once again he began seeking out his friends. “First I felt contentment. sometimes calling them at all hours to chat (“I just don’t care that much for sleep. wrote out the first seven chapters of his book. multiple sclerosis. Several times his teacher had to ask him to be quiet. although most cases of mania are not due to an underlying medical disorder. Mistakes in diagnosis can occur if a clinician thinks someone has an unstable mood due to bipolar disease. like I could conquer the world. he decided to open his own store. including pressured speech. amphetamines. careful observation for associated signs. Finally. Euphoria may be noted during intoxication with cannabis. when it is really irritability brought on by drug use. hyperactivity. First. Review [This case continues the vignette begun in the depression chapter review. then he might venture into publishing. and the opioids. page 52] After feeling like his old self for several days. Of course. Other medical conditions that can cause manic-like mood swings include AIDS.” these symptoms sound like mania. head trauma. Carl’s mood began to swing upwards. cryptococcosis. personality disorder. cerebrovascular accident. pernicious anemia and syphilis. Now he talked more in class. his horizons expanded. even the ups and downs of normal adolescence. As he told his PCP later.” he later said). In such instances. cocaine. Although the disinhibiting effects of alcohol are perhaps all too familiar. When in doubt as to the actual cause of moodiness. He started a long to-do list of all the preparations he needed to make and. treatment is wholly dependent on reigning in the substance use problem. mood stabilizers can end up being used to treat what could be mere moodiness. he’d write his memoirs. Limits on hospital stay or insurance reimbursement may encourage clinicians to come to closure too quickly. a daily charting of the ebb and flow of symptoms may help identify possible triggers. of course. but the absence of longitudinal features such as recurrent episodes not related to substance misuse. and poor judgment. Impaired judgment can result from the misuse of alcohol and just about any street drug. then I felt exhilarated. History. However.” As his mood lifted.Mania 64 As depicted in the riveting 1994 film “The Madness of King George. nearly taking over control of the discussion. epilepsy.

What is Carl’s most likely diagnosis? [p 56] 5. construct a differential diagnosis for Carl. try either of these two books: A Mind That Found Itself. Which symptoms does he have (or lack) that spell the difference between hypomania and mania? [p 61] 3. by Kay Redfield Jamison (1995). Published in 1908.org). after half an hour of discussion. A psychologist and professor of psychiatry at Johns Hopkins who has devoted her life to research and writing about bipolar disorder relates her own experiences with the illness in this riveting memoir. Which symptoms/signs of a manic or hypomanic mood episode does Carl have? [p 55] 2. he accepted a recommendation for treatment. . it is the classic biography of a person with bipolar disorder who was ill long before the modern era of medication began. What symptoms define the difference between a diagnosis of bipolar II and bipolar I? [p 61] 6. An Unquiet Mind. It’s free online from Project Gutenberg (http://www. 65 1. by Clifford Beers. It’s the best account we have of a bipolar patient’s inner life.gutenberg. What would you say to this family? [p 59] Further Learning For insight into the lives of patients who have immoderate mood swings.Mania Francine. How would you counsel Carl as regards prophylactic management? [p 59] 9. What acute treatment measures would you recommend for Carl? [p 58] 8. How would Carl’s symptoms have to be different to qualify for a diagnosis of cyclothymic disorder? [p 62] 7. persuaded him to return to his psychiatrist. [p 56] 4. Using the safety principle.

social. ideas of suicide. delusions or hallucinations. or Markedly decreased interest or pleasure in nearly all activities Symptoms 5+ of (mood or decreased interest must be included): Mood depressed or looks depressed Decreased interest or pleasure Change appetite or weight Change sleep Change psychomotor activity Fatigue Decreased self-worth Decreased concentration Death thoughts. Impaired work. hypomanic episode unless precipitated by somatic treatment for depression* Not better explained by schizoaffective. or slowed Bipolar II mood disorder Bipolar I mood disorder . social. severe preoccupation with worthlessness. not superimposed on other psychosis Symptoms cause clinically important distress or impair work. social. or personal functioning No manic or mixed episodes Not better explained by schizoaffective. personal functioning Exclusions Not GMC Not substance-related Not mixed episode Not within 2 months of bereavement (unless severe†) 66 Major depressive Sustained high. Hospitalized. or irritable mood different from usual mood for 4+ days Mania and depression for 1+ wks 1+ of: Psychosis Hospitalized Impaired work. Combining mood episodes into mood disorders. personal functioning Not GMC Not substance-related Not caused by somatic therapy* Not mixed episode Not GMC Not substance-related Not caused by somatic therapy* Not GMC Not substance-related Not caused by somatic therapy* Hypomanic Manic Table 2.Mood disorder tables Table 1. ECT. personal functioning A distinct change that others can recognize No psychosis Not hospitalized 1+ of: Psychosis. 3+ of (4+ if mainly irritable): Grandiose or ↑ self-esteem Decreased need for sleep Increased talkativeness Racing thoughts Increased distractibility Increased psychomotor activity Poor judgment Severity Clinical distress or impaired work. or personal functioning Types of Pattern Single depression Recurrent depressions Mixed Meets full criteria for both manic and major depressive episodes Major depressive disorder 1+ major depressive episode(s) 1 or more manic episode(s) May be major depressive episode 1+ major depressive episode(s) 1+ hypomanic episode(s) Single manic episode Most recent episode manic Most recent episode hypomanic Most recent episode depressed Most recent episode unspecified *Somatic therapy: medication. not superimposed on other psychosis Not GMC or substance-related Not better explained by schizoaffective. may be less) Sustained high. Symptoms and other criteria of mood episodes. Mood. Mood episode Exclusions & Other Features No manic. or irritable mood for 1+ wks (if hospitalized. bright light †Severely impaired functioning. social. expansive. expansive. social. mixed. duration For most of nearly every day for 2+ wks: Depressed mood or appears depressed to others. suicidal ideas or att. not superimposed on other psychosis Not GMC or substance-related Symptoms cause clinically important distress or impair work.

stereotypies. manic. Lifelong. mixed Bipolar II depressed With melancholic features With major depressive episode. seasonal major depressions materially outnumber nonseasonal episodes. as does full recovery or change of polarity. Feels no better when something good happens The episode occurs within 4 weeks of giving birth Major depression Bipolar I depressed Bipolar II depressed With postpartum onset Major depression Bipolar I depressed. Regular seasonal changes as described for 2 or more years. or hypomanic episode. The boundaries of the episodes are indicated by a switch between high and low or by a 2+ month period of remission.Mood disorder tables Table 3. either or both: Loss of pleasure in nearly all activities. No nonseasonal major depressions during this time. Disregard episodes where there is a clear precipitant. Major depression regularly begins at a particular season of the year. Mood specifiers that apply to current or most recent mood episodes and to dysthymic disorder. leaden Work or personal relations impaired by sensitivity not limited to depressed periods Does not have melancholia or catatonia in same episode 2+of: Immobility or stupor Apparently purposeless hyperactivity not influenced by external stimuli Mutism or extreme negativism Prominent posturing. manic. such as being unemployed every summer. cheerful with good fortune. sad with disappointment With catatonic features Major depression Bipolar I depressed. mixed. Description Criteria 2+ of: Increased appetite or weight Excessive sleeping Limbs feel heavy. manic. mannerisms or grimacing Echolalia or echopraxia 3+ of: Different quality of depressed mood from bereavement Consistently feels worse in the mornings Awakens at least 2 hrs early (terminal insomnia) Psychomotor activity markedly speeded up or slowed Marked loss of appetite and weight Excessive or inappropriate guilt feelings Can apply to: Major depression Dysthymia Bipolar I depressed Bipolar II depressed 67 With atypical features Mood reactivity. With seasonal pattern . mixed Bipolar II depressed With/ without full interpisode recovery Full remission between two most recent episodes In past year. 4+ episodes With rapid cycling These patients meet criteria for major depressive.

social.Mood disorder tables Table 4. personal functioning Depressed or loss of interest or pleasure. substance misuse . longest symptom-free period is 2 months 68 2+ of: Change in appetite (up or down) Change in sleep (up or down) Fatigue or low energy Poor self-image Indecisiveness or poor concentration Hopeless feelings Dysthymic Clinical distress or impaired work. mixed. longest symptom-free period is 2 months Depressed. social. Patient is sad. Symptoms and criteria of other mood disorders. resolve <6 months after stressor ends Major depressive. social. Not schizoaffective or other psychosis Not GMC. expansive. or Medication use caused symptoms History. mixed. 1+ months continuously ill History. duration Symptoms Hypomania when high. substancerelated No major depression 1st 2 yrs No manic. Not bereavement 2+ of: delusions. or elevated. or elevated. expansive. mixed or manic episode. personal functioning No manic. most days for 2 years. personal functioning Exclusions Many periods of hypomania plus many periods of mild depression for 2 years. substancerelated Not solely during delirium No other mood disorder better explains symptoms. irritable Duration not specified Depressed or loss of interest or pleasure. social. physical exam or laboratory evidence suggest a GMC has caused symptoms. hopeless Schizo. tearful. Mood. personal functioning Not solely during delirium No other disorder better explains symptoms. hallucinations. or major depressive episodes first 2 years. irritable Duration not specified Depressive symptoms begin within 3 months of stress. when depressed. Substance use Clinical distress or impaired work. or impaired work. delusions and hallucinations w/o prominent depression Not directly caused by GMC. or appears depressed to others most of the day. personal functioning Doesn’t fulfill criteria for other Axis I disorder. does not meet criteria for major depression Severity Clinical distress or impaired work. or negative symptoms For 2+ wks. Cyclothymic General Medical Condition Clinical distress or impaired work. disorganized speech.Adjustment affective disorder w/ depressed mood Distress > expected for stressor. social. physical exam or laboratory evidence that either: Symptoms developed within 1 month of intoxication or withdrawal. disorganized or catatonic behavior. or hypomanic episodes Never cyclothymic Not solely in context of chronic psychosis Not GMC.

though he carried out scientific experiments in his room at age 12. one time in Italy he heard voices “like telepathic phone calls” from individuals. lonely little boy who stayed indoors to read when others were outside playing. John Nash’s.) His thinking unhinged and his behavior increasingly erratic. and that 23 was his. His parents (who were loving and sympathetic) and his younger sister all recognized that he was different. Over the next 30 years he was intermittently extremely psychotic. he became acutely and severely psychotic. As a child. it’s still happening when you wake up. that powers from outer space were communicating with him through the New York Times. favorite prime number. which markedly reduced his delusions. At age 30. and had trouble following directions. John Nash was a solitary. and he noticed that men were wearing red neckties in an effort to send him signals about a crypto-communist party. daydreamed. He imagined he had a central role in combating threats to world peace. He thought that his bridge partner could read his mind. He believed that he was to become Emperor of Antarctica and that Life magazine’s cover photo of Pope John 23 was really one of him. He referred to himself as the “Prince of Peace” and “The Left Foot of God. alienating experience that mystifies and terrifies everyone it touches. He talked a lot.” He was diagnosed as having paranoid schizophrenia and treated with chlorpromazine. who noted peculiar behavior such as playing a single chord on the piano or leaving ice cream to melt over clothing he’d taken off. (Supporting evidence: he noted that John wasn’t the Pope’s original name. Psychosis is a devastating. where everyone knew something you didn’t. He concluded that the Italian words were being fed into a machine that translated them into English and inserted them 69 . A brilliant mathematician (he started graduate school at age 20). even in college he was considered snobbish and odd by his peers. perhaps followed.Chapter 5 Psychosis and Schizophrenia If you’ve ever had a dream in which you were being watched. sometimes even the doctor. In a letter (written in four colors of ink) he complained that space aliens were ruining his career. then you’ve had a taste of what it is like to be psychotic—except that if you’re psychotic. John had no close friends. odd. he was finally admitted for the first of several psychiatric hospitalizations.

The most common delusions in schizophrenia are those of persecution (someone is following. Brief definition: a delusion is a fixed. he had already published the work that led to his 1994 Nobel Prize in economics.” Typically in schizophrenia. all did it…” He put salt and pepper into his tea. in which the individual shows little emotion—no lilt to the voice. sometimes close by or just outside the room.2. Although schizophrenia patients can have visual hallucinations. This concept embraces several behaviors that suggest something is missing from the patient. (2) hallucinations. the John Nash character. not added to. 70 Symptoms of psychosis The history of John Nash illustrates some of the psychotic symptoms found in people with psychosis. and this happened many years ago). that the television is sending encoded messages especially to you. The five principal symptom areas are: (1) delusions. such as believing that you can read minds. command or. It can involve any of the five senses. Negative symptoms. threaten. or trying to harm you). By that time. these voices seem entirely real—sometimes coming from far away. everybody did it. typically these (as well as hallucinations of smell. as is true of with hallucinations and delusions. spying upon. which John Nash may have shown to a degree—for many years his attention was so preoccupied by his delusions that he could do little math. taste. Santa Claus. such as ghosts and. (3) negative symptoms.4 then one would be able to say nobody did it. . false belief.3. Whatever the content of the delusional belief (they are covered in greater detail in the chapter on interviewing). John Nash heard voices “like telepathic phone calls. Each of them carries the message that the patient is in some way out of touch with reality.Psychosis into his brain. then complained that it tasted bad. still other patients hear them in their heads. At one time. In the Oscar-winning film of A Beautiful Mind. Judging from the biography by Sylvia Nasar. or that electrodes have been secretly implanted in your brain. Hallucinations. and touch) are found in psychoses due to physical disorders. (4) disorganized speech. appears to have ongoing visual hallucinations of imaginary friends. Many types of delusions are possible. A letter he wrote when he was 39 read in part: “If all the atomic powers of the security council of the United Nations did an action. as portrayed by Russell Crowe. it is fixed—the person cannot be persuaded that it is false. and they were numbered 0. poor eye contact. Delusions. and (5) disorganized behavior. There may be one voice or many that can ridicule. All sorts of real events and conditions can get pulled into these delusions. soothe. and once poured water onto those who passed through a doorway below him. and little in the way of facial expression or hand gestures. 1. this was entirely a fiction. I once treated a woman who had ankle edema due to kidney disease. but hallucinated sounds are the most common in schizophrenia. infrequently. A hallucination is a sensation that the person only imagines. such as those about space aliens and being a religious figure. Patients often recognize these voices. She thought that water was being pulled downward into her legs by gravity machines installed in her basement by Nazis (she’d been ill a long time. These are false ideas or thoughts that a person believes to be true. Not included are widely held cultural beliefs. for kids. but sometimes they are of strangers. John Nash had many such delusions. Another is a lack of volition. no matter how improbable. An obvious negative symptom is flat affect (also know as affective blunting).

The fragment of John Nash’s letter quoted in the vignette demonstrates a degree of disorganization. Another such patient was the killer of University of California student Tamara Tarasoff.” terrorized New York City women in the 1970s.. When severely psychotic. On the other hand. which requires mental health workers to protect people from a mental patient’s threats. even when the situation calls for extended speech. the serial killer who. The consequent lawsuit led to the Tarasoff ruling. by some . John’s behavior was occasionally disorganized—for example. intentionally harming another person is unusual. but another person might be hard-pressed to understand. The risk of either tragic outcome—suicide or violence against others—is only one reason to provide careful diagnosis and competent treatment for psychotic individuals. an especially serious consequence in some instances of psychosis. however. Patients with schizophrenia often become suicidal. as “Son of Sam. they may grimace. prisoners in solitary confinement)** Delirium with psychosis Dementia with psychosis Mood disorder (bipolar I or major depressive disorder) with psychosis Schizoaffective disorder Schizophreniform psychosis Schizophrenia Schizophrenia The best-known chronic psychosis is schizophrenia. ( See pages 85 and 50 for further discussions of violence and suicide. Such speech may have meaning for the individual. psychotic patients are not usually violent. as in the case of Sam Berkowitz. It is one of the most important public health problems in the United States. Disorganized behavior. Disorganized speech. or perform rituals that have meaning only for them.) Differential diagnosis Besides indicating a variety of symptoms. A patient whose psychosis is dominated by disorganized behavior is sometimes referred to as catatonic.” disorganized speech moves from one idea to another without an obvious thread. For convenience. Psychotic patients may become extremely excited. and anhedonia—the inability to enjoy once-pleasurable experiences. However. however. John Nash was never violent. the word psychosis can also mean a class of illness that includes schizophrenia and other. everyone speaks of it as a single entity. maintain postures for many minutes.g. in fact. The speech of some patients becomes stilted or cluttered and may contain made-up words. engaging in frenetic activity that often does not appear goal-oriented. Here is a reasonably complete listing: Psychosis due to substance use Psychosis due to a medical condition Isolation psychosis (e.Psychosis 71 Other negative symptoms are alogia—talking very little. It can happen. adding salt and pepper to his tea. and 10–15% eventually take their own lives. either by reporting them to the police or by other means. though in reality it’s probably a group of diseases that have many symptoms in common. less well-known disorders. Sometimes called “loose associations.

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estimates costing as much as all cancers combined. In recent decades, improved treatment has enabled the release of many chronically hospitalized patients into their communities, though follow-up care has lagged so far behind that many stop taking their medicines and relapse. So many end up living on the streets that, in larger cities, up to half the homeless have some form of psychosis, most often schizophrenia. They gravitate to petty crimes and misdemeanors, thus becoming wards of the criminal justice system. The symptoms of schizophrenia are many and varied. Of course, the percentages will vary, depending on the series reported. Delusions. The vast majority of schizophrenia patients (over 90%) have delusions at some point or other. In schizophrenia, persecutory delusions are by far the most common. Hallucinations. About half of all schizophrenia patients experience hallucinations; auditory predominate, but about 15% report visual hallucinations. Abnormal behavior. Between 5 and 10% will have symptoms of catatonia, such as stupor, negativism, stereotypies, posturing, and catalepsy. Abnormalities of appearance may include bizarre clothing and grooming styles, poor hygiene (as was true of John Nash at the height of his illness), and hyperalert scanning of the environment for threats or the source of voices. Overall, around 15% of patients show significant abnormalities of behavior. Perhaps 10% of schizophrenia patients become aggressive; a few will commit violent acts ranging from simple assault to attacks that lead to severe injury or death. Violence is especially likely in patients who are young, male, have a past history or violence, refuse medications, and misuse substances such as alcohol and street drugs. However, the majority of schizophrenia patients are no more prone to violence than is the general population. Disordered speech. Derailment and tangentiality are found in roughly half of schizophrenia patients; around a quarter are illogical or incoherent. Disordered emotion. Around 20% of acutely ill patients show inappropriate affect (usually considered a positive symptom of schizophrenia); around half display affect that is flattened or blunted. Around 40% of schizophrenia patients experience anhedonia (the loss of feeling). Psychotic patients may also respond inappropriately to other people’s emotions—laughing at someone else’s grief, for example, or giggling without obvious cause. Around 70% of acutely ill, but only around 10% of chronically ill schizophrenia patients experience depression. Some become depressed as they begin to recover and gain insight. One of my earliest patients as a medical student was a psychotic (yet insightful) young woman who cried bitterly, stating that she knew she had schizophrenia and feared she would end life on a back ward of a state hospital. Apathy. Over two-thirds of schizophrenia patients are apathetic, as shown by low energy, poor grooming or hygiene, or lack of persistence in school or on the job. There is often loss of usual interests, including interest in sex with other people. Attention and cognition. Half of patients are inattentive, in social or testing situations. Working memory, long-term memory, the ability to abstract and plan, and language comprehension are all compromised. Insight. My early medical student patient notwithstanding, typical insight in schizophrenia is terrible. With denial of illness, judgment falters, sometimes fatally, as patients fail to adhere to treatment recommendations—like John Nash. Various medical consequences. Heavy cigarette smoking is the rule, and patients may abuse substances (some clinicians think that alcohol and drugs may serve as home remedies for

Psychosis hallucinations). Their sleep may suffer; relatives sometimes note that they hear acutely ill schizophrenia patients pacing and mumbling to themselves throughout the night.

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Schizophrenia subtypes
We commonly recognize several subtypes of schizophrenia, characterized by the presence or absence of the now-familiar five basic symptoms: Paranoid. Persecutory delusions characterize people with paranoid schizophrenia, who may seem pretty normal unless a topic related to their delusional ideas comes up. Paranoid schizophrenia often begins later than the other subtypes—typically, when the patient is 30 or older. Disorganized. These patients think and speak illogically. Facial expressions and mood tend to be stiff or unchanging, though some patients may laugh or giggle inappropriately. Behavior may be bizarre and not understandable—carrying around collections of paper cups or gesturing in ways you cannot understand. Catatonic. Abnormalities of motion are prominent. These include frozen postures (holding uncomfortable poses, sometimes for hours at a time) and pronounced negativism, such as a patient turning away from an interviewer. Undifferentiated. This term is used when the patient doesn’t meet full criteria for any of the three subtypes listed just above and in Table 6. A diagnosis of exclusion, it is the type most commonly diagnosed today. (A strong minority of patients has paranoid subtype, whereas the number of disorganized and catatonic types is relatively small.) Residual. With treatment, most patients improve enough that they eventually lack sufficient criteria for a diagnosis of acute schizophrenia; then, we say the patient is in the residual phase. This person is still ill: You’ll still find a few negative symptoms such as flattened affect, lack of volition or reduced speech output, or there will be remnants of positive symptoms such as odd manner of self-expression (from disorganized speech), illusions (related to hallucinations), odd beliefs (from delusions) or peculiar behavior (from disorganized behavior). Although these subtypes seem pretty clear-cut, in practice patients may change subtypes more than once in the course of a long illness. Indeed, John Nash, called paranoid schizophrenia for many years, at times had disorganization of his thinking and behavior; in hindsight, “undifferentiated” might seem a more appropriate diagnosis. But in the end, it doesn’t make much practical difference: the subtype designation confers little predictive information, beyond the simple diagnosis of schizophrenia itself. Making the diagnosis Because it falls so low on the safety hierarchy, clinicians shouldn’t diagnose schizophrenia unless a patient has had symptoms for at least 6 months. Besides the requisite symptoms and time duration, we must also be careful to rule out other possible causes of psychosis. These include mood disorders with psychosis, general medical and substancerelated illnesses that have psychosis as prominent symptoms. The symptoms must also have been serious enough to cause impairment of the patient’s work, social or personal life. The criteria are summarized in Table 6 (page 87.

Course of illness
In a number of ways, John Nash is typical of schizophrenia patients. Before he fell ill, he was an isolated, quiet young man with few friends. This personality type, sometimes called schizoid,

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occurs in about 25% of patients (schizotypal and paranoid are the other personality disorders that sometimes precede schizophrenia). However, most people with abnormal personalities do not develop schizophrenia, and many schizophrenia patients do not qualify for a personality disorder prior to falling ill. By far the majority of patients are young (teens and 20s) when they first fall ill. The onset of schizophrenia is usually gradual; then, most patients pursue a chronic course. This means that, even with competent treatment, patients continue to have mild symptoms or are at risk for relapse if they discontinue medication. John Nash always responded well to antipsychotic agents, but refused to take them consistently, thereby leading to years of reclusive unemployment. In his mid-50s, he became better able to ignore his delusions; once again he could do mathematical research. His improvement provides an excellent example of residual phase schizophrenia. Other, less fortunate patients remain so ill that, to live in the community, they require careful supervision of their medications. Some become street people, and a few cannot survive at all outside the walls of an institution. The suicide rate among schizophrenia patients, about 10%, is especially high in younger patients and in men who have been recently diagnosed, depressed, or unemployed. Those who have been recently discharged from a hospitalization are at greatest risk. Even excluding suicide, the overall lifespan of schizophrenia patients is around a decade shorter than for non-affected Americans. Contributing factors include cigarette smoking, substance use and poor nutrition, through the mechanisms of cancer, coronary artery disease, diabetes and high blood pressure.

Sidebar: Improvement and Recovery
Trying to predict outcome has occupied researchers for many decades. It is especially difficult for new-onset patients who have not been ill very long; after 5 years of illness, it is safe to predict continuing illness. In the short term, those who are likely to experience an outcome that is better than average tend to be characterized by some of the factors listed below. Asterisks indicate those features that are potentially modifiable. • Short duration of untreated psychosis.* One of the most robust findings is that a brief duration of symptoms prior to initiation of treatment is associated with quicker remission, more stable remission, fewer positive symptoms, and improved functioning in social settings. Early (within, say, 6 weeks) positive response to treatment. Good personal, social or work-related functioning at intake. Female sex. Women with schizophrenia are more likely than men to have good interpersonal relationships and to live independently. Cognitive remediation.* Using group formats to teach strategies to improve cognition can improve cognitive performance (including memory, attention, and executive functioning) and psychosocial functioning. Sticking with treatment.* Psychiatric education.* Teaching patients and relatives about the basic facts of psychotic illness, such as symptoms, treatment adherence, patient functioning, and rehospitalization appears to reduce relapse rates, at least over the short term (one year).

• • • • • •

now. Poor insight is reported in 50-80% of schizophrenia patients. and much more likely to be married. Typical age of onset is in the late teens or early 20s. For reasons still not understood.and middle-income countries such as India. upwards of 80% will relapse within 5 years. despite a sometimes long duration of untreated psychosis. 40s or even later. though overall it affects men and women about equally. Poor insight (not just related to poor compliance). depending on the study—but they are well-documented: patients who would meet any set of rigorous criteria yet on follow-up after months or years appear free of all symptoms and restored completely to their premorbid functioning.. more likely to be employed. a few patients appear to recover completely. though the paranoid subtype may begin in the 30s. over half of patients will not adhere to treatment regimens. The presence of negative symptoms at baseline. For those at the more extreme end of this range. though clozapine has been reported to reduce suicidality. Treatment with traditional neuroleptics doesn’t reduce the suicide rate much. use of depot drugs may provide some benefit. Greater severity (e. even partial noncompliance is related to relapse. Their numbers are not large—perhaps around 10%. Of those who do not take medications. schizophrenia is far from rare today—about 1% of all adults have it—and it is found in every culture on earth. That is. and not much is known about how to predict this astonishing outcome. Poorer social functioning at intake.* One study reports that those with longer times to treatment experienced greater reductions in grey matter volume.* Cognitive impairment. The greatest danger comes in the first year after diagnosis. depot risperidone is available. Oral atypical antipsychotics are complied with better than traditional oral agents. and Hong Kong tend to have better outcomes. probably because so many schizophrenia patients cannot take good care of themselves and descend into poverty—the social drift theory of schizophrenia. Poor early response to treatment.* This is a major contributor to relapse.* Overall suicide prevalence is probably around 5%. Singapore. Epidemiology and etiology Known for centuries. Contrary to the usual view of schizophrenia as a chronic disease. more positive symptoms) at onset of disease.g. Poor compliance with medications. even into the early teens and before. . Many months (even years) of initial untreated psychosis. but risk continues throughout life. Misuse of substances such as alcohol and street drugs. In some way at some time. males tend to develop it a few years earlier than females. Another intriguing.Psychosis On the other hand. compared to patients in most Western countries they are better socialized. This finding may be related to psychosocial factors such as relatively low substance use. There are few studies of these incredible patients. Unrecognized depression that leads to suicide attempts or completions. well-substantiated finding is that patients in low. whether or not they take medication. a poor outcome may be heralded by: • • • • • • • • • • 75 • Early onset of illness. It is encountered more often in disadvantaged social and economic groups.

We’ve already mentioned the three personality . but does not itself appear to be causative. a genetic component to schizophrenia had been well-established. Depression. it is clear that we are still far from completing our picture of what causes schizophrenia. has also been implicated. The excess of schizophrenia patients among the lower social strata is probably best understood as the downward mobility of the “social drift” hypothesis. and (2) amphetamine psychosis may be mediated by increased dopamine activity. • • With so many threads in the tapestry left untied. Over the years. this abnormality appears to be present at least from the onset of the disease. (One of John Nash’s two sons. Glutamate. yet another neurotransmitter. And chaotic. obsessive-compulsive disorder and panic disorder are the other psychiatric conditions that often occur. Response to medications have led to hypotheses that a disturbance in neurotransmitters may set up vulnerable patients for psychosis. In many cases. the disorder probably has more than one root cause. Dopamine has long been the dominant suspect. a child of 2 ill parents runs a nearly 50% chance of developing schizophrenia. An excess of schizophrenia in second-generation immigrants suggests social causation. Over the decades. social factors have been explored. first-degree relatives have 5–10% chance of developing the disease. By the time John Nash fell ill in the early 1950s. Although most relatives of patients with schizophrenia do not have a mental illness.) The greater the genetic loading. Of course. highly emotional family life may contribute to symptom relapse. Patients may also have less total brain tissue and grey matter (and more CSF). whereas increased dopamine activity may be related to delusions and hallucinations. Factors as diverse as prenatal exposure to viruses (more people with schizophrenia are born during the winter months) and obstetric complications suggest a role for injury to the developing brain (this process extends through the late teens into the 20s. had the disease. The balance of the evidence suggests that a multiplicity of factors must be in play: a genetic diathesis released by developmental factors such as obstetrical complications. Indeed. also a mathematician. such as exposure in childhood to adverse social conditions. the fact that atypical antipsychotic drugs block both dopamine and serotonin receptors suggests a more complicated overall picture. the greater the risk. Comorbidity Substance use (especially nicotine. poor prenatal care or maternal substance use and by stressful environmental factors later in life. typical antipsychotic drugs. based on two findings: (1) the dopamine blockade caused by the older. well within the usual age of onset). additional diverse factors related to the brain and neurological functioning have expanded the areas in which the search for the etiology of schizophrenia must be conducted: • • Size of ventricles is larger on average in schizophrenia patients than in matched controls. dozens of studies have shown beyond doubt that what we inherit accounts for half or more of the risk of developing schizophrenia.Psychosis 76 Most researchers believe that schizophrenia is a collection of disorders with a variety of causes. Weinberg suggests that reduced dopamine activity may be responsible for negative symptoms such as lack of volition. used by about 80% of schizophrenia patients) is a frequent complicating factor.

Moreover. Acute phase For most disorders. partly because psychosis is a confusing condition that can take many forms. it is important to begin drug therapy at once: considerable data suggest that effective medication early in the course of the illness. Accurate diagnosis depends on knowing not just the symptoms but the patient’s lifetime course of illness. unnecessary. and sometimes even dangerous—as well as delay treatment that is appropriate and effective. 5 or 10 mg once a day. good social adjustment prior to becoming ill (reliable worker or student with stable personal relationships). upsetting emotional factors (such as death of a parent) that could conceivably cause psychosis. Many patients work. The error is extremely serious because an incorrect diagnosis of schizophrenia can promote treatment that is lengthy. People with psychotic bipolar mood disorder also usually recover completely. with effective treatments that can return them to their lives. Editorial: Caution Advised Throughout the Twentieth Century. start with one of the atypicals. partly because clinicians sometimes don’t give enough thought to the diagnostic process. and symptoms beginning later than age 30. Although most do need long-term treatment. If the first choice isn’t effective. perhaps olanzapine (Zyprexa). a strong family history of mood disorder. at weekly intervals. Treating schizophrenia Even 50 years ago. though they may improve greatly.Psychosis 77 disorders—schizoid. schizophrenia carried an especially gloomy prognosis. it is not effective as a sole treatment. For the first month . the course is usually chronic. most patients do not resume their former level of functioning. risperidone (Risperdal) or quetiapine (Seroquel) instead might be. the outlook is much brighter. A 4–6 week trial is generally accepted as a standard treatment trial for any of the antipsychotic agents. there are psychotherapy alternatives for patients who don’t want to take drugs. jobs. which usually remits completely once the underlying illness has been addressed successfully. mood symptoms (mania or depression). The treatment of all schizophrenia subtypes is about the same. schizotypal. Contrast this prognosis with that of a psychosis caused by substance use or a physical disease. This error still happens today. reduces the likelihood of relapse and limits social decline—possibly because early treatment averts changes in brain structure. then increase it gradually. brief course (symptoms present less than 6 months). For example. In schizophrenia. many patients were diagnosed with schizophrenia who later turned out to have another illness entirely. and paranoid—that may be present for years before the onset of acute illness. and families. many patients spent years in mental hospitals. Now. they are far less likely than those of their grandparents’ generation to require chronic institutional care. A number of features can suggest that a patient does not have schizophrenia: abrupt onset. Schizophrenia is an important exception. though their jobs may be less complex than education and training has prepared them to do. with consistent follow-up care. until the target symptoms begin to disappear. which means that once illness strikes. Although psychotherapy can help manage schizophrenia. medication is indispensable.

the usual practice of gradually tapering off the current drug should be followed. and they are far less likely to have longer-term side effects. Clozapine (Clozaril). to reduce the risk of TD. has the longest track record of success in patients who are especially difficult to treat. especially tardive dyskinesia (TD). Some may resent being controlled by doctors or think that medicines are harmful or unnecessary. A recent metaanalysis found that cognitive-behavioral therapy (CBT) may help reduce the severity of delusions and other symptoms. For someone who’s been taking an older drug for many months. Previous experience is one of the most important factors to consider in choosing from the growing list of available drugs. Usually. prescribe one of the older drugs only if the patient is already well established on it without major side effects or newer drugs haven’t worked. the best solution may be a drug that can be given by injection once or twice a month. This information . A treatment period of 6 months or more may be necessary to determine whether this drug will help. how to request cooperation without alienating the patient. That’s why clozapine is usually reserved for patients who simply don’t respond well to other treatments. Social skills training seeks to improve patients’ adaptation to the environment. medication use and side effects. doses below the equivalent of 300 mg/day of chlorpromazine will probably be ineffective. The newer drugs are also more likely to improve disorganized thinking and negative symptoms. avoid the older antipsychotic agents in favor of newer ones. early relapse. administer the Abnormal Involuntary Movement Scale (AIMS). thereby reducing stress. Every 6 months. If an older antipsychotic is needed. The acute phase of illness is an excellent time to bring the family in for education about symptoms. clozapine may be underutilized. consider changing to a newer agent. someone who is psychotic and acutely agitated may also need calming with a benzodiazepine such as lorazepam (Ativan) or clonazepam (Klonopin). so patients are more likely to accept them. and communication skills—for example. as long as they are given in adequate doses. especially when a lower-key approach can be urged on relatives who are overly involved with and critical of the patient. Because they have so many more side effects. but even the newer ones can cause weight gain and metabolic problems such as an increase in serum glucose and lipids. Because of its side effects. They have relatively few immediate side effects. Every 6 months. such as haloperidol (Haldol) or fluphenazine (Prolixin). Of the atypical antipsychotics. Other movement disorders such as akathisia or parkinsonism can be addressed fairly easily by adding an antiparkinson agent such as trihexyphenidyl (Artane). Watch carefully for evidence of tardive dyskinesia or another movement disorder. When making any change. risperidone (Risperdal) is now also available in a depot form. How well patients accept any drug depends a lot on their comfort. Family therapy can help prevent relapse. but it occasionally causes agranulocytosis. For one who has repeatedly discontinued oral medication. Several forms of psychotherapy can augment the effects of medication. This is especially the case with the older antipsychotics.Psychosis 78 or two. so side effects must be corrected quickly. and doses above 1000 mg/day aren’t likely to improve response. A drug with few side effects that has worked well in the past (and that the patient will accept) should perform well again. problem solving. Many patients refuse oral medications. the original atypical antipsychotic agent. Note that most studies find there is very little difference in response rate among the older antipsychotics. but it is still the best-studied atypical. check to see whether patients show any symptoms of TD. and it has the best track record in studies.

Psychosis 79 can help decrease the stress for both patient and family. such as with a first episode. the term took off. and divalproex (Depakote). it is important to watch carefully for recurring symptoms. it comes up too frequently to be ignored. deserves to be left out of introductory textbooks. the physician. consider using antidepressant medication. For example. The term was introduced in 1933 by a well-meaning doctor named Jacob Kasanin. If symptoms resurface. patient. Other potential adjuvants include lithium. When patients stop drug treatment completely. it has only grown more popular. unhappily. In some cases. and very loosely by others: A few years ago. improvement in cognitive symptoms is likely to be modest. • • • Maintenance phase Once the patient has stabilized and has no hallucinations or delusions. . Because this description fits a lot of patients (many schizophrenia patients are at some time depressed). For a schizophrenia patient who has been depressed. the concept is important in that it helped us understand that not all psychosis is schizophrenia. the use of estradiol (100 µg/day patch) seemed to reduce positive (though not negative) psychotic symptoms when compared with antipsychotic drugs alone. but there are several steps you can take in the face of a poor treatment response. carbamapezine (Tegretol). Remember that cognitive deficiencies and negative symptoms are better treated with atypicals than with the traditional antipsychotic drugs. in a 2008 study. who used it do describe 9 patients who had both psychotic and mood symptoms. in my opinion. Finally. ECT may relieve persistent catatonic symptoms. the case management skills of a social worker who periodically visits the patient in the community can help assure good continuity of care. however. In the intervening 75 years. one psychiatrist famously wrote that he gave this diagnosis to most of his patients! Historically. An adjuvant treatment may be helpful. Some studies have found repetitive transcranial magnetic stimulation (rTMS) effective in treating negative symptoms. Anyway. and family will share two goals: reduce medicine to the absolute minimum needed to prevent recurrence and watch carefully for symptoms of relapse. • • • • Be sure that your patient is really taking the prescribed medications (blood level checks can help determine this). it could even help prevent relapse. Has the patient used this treatment long enough? Some apparently refractory patients just take longer (perhaps months) to improve. Now it is used loosely by some clinicians. Poor treatment response Using multiple antipsychotic drugs usually only piles one side effect upon another. it will be easy enough to increase the dose again. before they can become severe. it may be advisable to scale back the medicine very gradually. perhaps by about 20% every 6 months. Schizoaffective Disorder Here is a confusing diagnosis that.

you will probably diagnose actual schizophrenia. Currently. manic. Once identified. the patient must be rediagnosed. the patient seems confused or perplexed. If the symptoms persist. we’ve achieved something. schizoaffective disorder was the only diagnosis listed that included no criteria whatsoever. not progress to a chronic course of illness) if any 2 of the following features are present: • • • • The actual psychotic symptoms begin within 4 weeks of the first noticeable change in the patient’s behavior or functioning. both the inter-rater reliability and diagnostic stability for schizoaffective disorder appear to be low. Affect is neither blunt nor flattened. In my view. numerous reviews have failed to substantiate schizoaffective disorder as a separate. If we do use the designation schizophreniform disorder. especially when this determination is likely to be retrospective. which only requires a balance of mood and psychotic symptoms). If they have remitted. For one thing. When most psychotic. Premorbid social and job functioning are good. Schizophreniform Disorder No difficulties with criteria present themselves with schizophreniform disorder. Some clinicians worry that using the term could lead to treatment that is substandard. possibly. .Psychosis 80 When in 1980 DSM-III was first published. Some experts regard the concept as a psychotic mood disorder. Devised in 1939 by Gabriel Langfeldt in Germany. discrete diagnosis. This time frame reflects the findings from study after study that patients who have had psychotic symptoms for briefer periods of time may recover completely. they aren’t derived from hard evidence that they can actually predict anything. A patient will be relatively likely to recover (that is. it is difficult to ascertain the absence of mood symptoms. an acknowledgment that the clinician isn’t sure enough to make a definitive diagnosis. except that its total duration must be less than 6 months. made by people who are very concerned about and focused on the drama of an ongoing psychosis. that accomplishment is to muddy the diagnostic waters and. or mixed mood episode. the individual must have had delusions or hallucinations without prominent mood symptoms. also have a major depressive. the term designates patients who simultaneously meet the “A” criteria for schizophrenia and. That’s because this term is really just a place-holder. Finally. schizophreniform disorder is defined exactly like schizophrenia. others see it as either a middle ground in a spectrum between mood and schizophrenia or a collection of cases from both categories. and revised again for DSM-IV. Criteria were added in DSM-III-R in 1987. In recent years. you can specify a subtype—bipolar or depressive. for a substantial part of the illness. For another. Once 6 months have passed. you may change the diagnosis to something different such as a mood disorder with psychosis or a psychosis caused by a medical illness or by substance use. There are some serious problems with these criteria. besides the fact that few of Kasanin’s original patients would qualify. based on several factors. (The requirement of no mood disorder symptoms for a substantial period of time is only one of the ways in which DSM-IV criteria differ from those of ICD-10. We think that by diagnosing schizoaffective disorder. we are encouraged to assign prognosis. For at least 2 weeks. to distract us from making a diagnosis that can actually predict something about the patient.

When he sent the neighbor (courtesy copy to the sheriff) a typewritten note threatening to “use my . only some cymbidiums that he had nursed back to life when the local KMart tossed them out after Christmas. then ran it alone for several decades after his father died. He had repeatedly called the sheriff to complain and he yelled in outrage when no one took him seriously. or otherwise mistreated. they express them with appropriate affect. examples include Wilson’s disease. the patient feels in some way intentionally cheated. It is rare as psychoses go. There are many possibilities. Grandiose—the patient has a special talent or identity. cerebrovascular disease. This type appears to be rare. is in love with the patient. . He had no hallucinations or other psychotic symptoms. His son told the caseworker that Orville didn’t have any precious orchids. Especially beware organic causes of delusions in patients who are older and have no family history of psychosis. This is by far the most common subtype. drugged. often of status higher than the patient’s (such as a television actor). When they do talk about their delusions. These delusions are not bizarre—that is. with a prevalence of perhaps 3 in 100. Orville started out in the nursery business with his father. and the patients are often widowed and middle-aged or older. Except when discussing the content of the delusion.Psychosis 81 I feel that schizophreniform disorder is sadly underused. such as delusional infestation by parasites. but each time he had refused medication and left against medical advice.44” if his greenhouse wasn’t left alone. those with the much less common delusional disorder have only one—delusions. he was finally committed to the county mental health unit. The delusions can be of several types: Persecutory—like Orville. Delusional Disorder Schizophrenia patients have two or more different psychotic symptoms. This may be more common among men than women. just as Orville was outraged that his calls to the sheriff had gotten no results. the ideas or events could conceivably happen (as opposed to extravagant beliefs such as being abducted and probed by Martians). He was nearing 65 himself when he became convinced that his neighbor was stealing precious orchids from him. followed. Twice in the last couple of years he had been taken to a private psychiatric hospital. these patients can seem quite normal. Best guesses currently deny a significant genetic relationship between delusional disorder and schizophrenia. Jealous—the individual’s partner has been unfaithful. Somatic—these people believe that they have some physical illness or defect.000 persons. and dementia. so studies adequate to determine etiology have not been done. hence the term encapsulated delusions. It is of great value to defer diagnosis of schizophrenia until you can be as certain as possible that you haven’t missed some other diagnosis that has a better prognosis. such as being a rock star or Jesus. Erotomanic—someone. slandered. Delusional disorder is more common in women than men.

The voice was her ex-husband’s. the best approach is not to address the psychosis directly but to treat the underlying disorder. The important issue is not that they are so very common (indeed. By the time he finally sought mental health care. some patients appear to respond to an SSRI. These two vignettes demonstrate that psychosis can be caused by physical illness or substance misuse. she complained to her doctor that she felt tired and grouchy and that she heard talking when no one was around. Within a few days he began to hear chanting. Danny had been a heavy drinker. hyper. Psychosis Due to Medical Disease Or Substance Abuse When Helen was 24. her hallucinations vanished and she successfully completed the treatment for hepatitis. unrelenting disorder that interferes with work and alienates people from their families and friends. because these two classes of diagnosis require treatment that is different from all other psychoses. hyper. a serious automobile accident required her to undergo several blood transfusions. Over the past few years. most delusional disorder patients greatly improve. they belong at the very top of every differential diagnosis for psychosis. strokes. the need for medication may be permanent. As with Helen and Danny. Laboratory testing showed that Helen’s thyroid gland had almost stopped working—probably an effect of the interferon. consuming over a pint of bourbon a day.Psychosis 82 Treatment and course If they can be persuaded to take medicine. it is difficult to come up with prevalence or incidence rates—in all likelihood. They are the first causes to rule out. he wondered whether someone had put a transmitter into his ear. delusional disorder is a chronic. Huntington’s disease. and because missing such a diagnosis can be potentially catastrophic.” he stopped drinking. With replacement thyroid hormone therapy.and hypo-thyroidism. within 2 weeks the voices melted away without medications. Although you may never encounter a psychosis due to interferon. and it told her to stop the interferon because it was causing her hair to fall out. However. chronic obstructive lung disease. Despite an admitting diagnosis of schizophrenia. Psychotherapy alone is of no value. When he developed what he called “stomach flu.and hypo-parathyroidism. Cushing’s syndrome. Lyme . brain tumors. She didn’t learn until 10 years later that she had contracted hepatitis C. Untreated. For at least 20 years. he could hardly concentrate— voices yelled “Don’t tell them about your drinking!” and “Why don’t you just kill yourself?” He was so terrified that he admitted himself to a locked psychiatric ward. the traditional neuroleptic drug most recommended for delusional disorder has been pimozide (Orap). These etiologies occur just infrequently enough to lull us into inattention. even if they are (usually) not the most likely. a consultant rediagnosed his condition as an alcohol-induced psychosis. neither situation is especially common or rare). but the family’s involvement is at least as important as in schizophrenia. especially if treatment begins without delay. Rather. AIDS. If these drugs don’t seem to work. the list of medical disorders that include psychosis among their symptoms is long. It includes adrenal insufficiency. After taking the prescribed interferon for several weeks. epilepsy. so one of the newer antipsychotics should be tried first.

the hallucinogens.Psychosis 83 disease.. The same line of thinking suggests we shouldn’t succumb to a request for our trust. Others include amphetamines. To help the patient feel listened to. “If I thought that someone was reading my mind. and tertiary syphilis.” Such behavior reinforces the patient’s hallucinations or delusional thinking. Acknowledge the content of the delusion or hallucination and the emotion carried with it. I’d feel pretty upset. a question such as “Could it be that…” or “I wonder whether…” gives the patient space to reconsider. opioids. possibly to volunteer a nonpsychotic conclusion. too. carefully monitoring your facial expressions and body language so as not to show disbelief. even if you disagree with the content. Acknowledge their reality.” On the other hand. whatever they are. By emphasizing emotional elements. Accept what’s said. An approach to psychotic thinking • • • Our own discomfort sometimes prevents us from discussing delusions frankly.g. and phencyclidine (all during intoxication). angry—and ask the patient how it feels. Following are some basic guidelines for dealing with psychotic thinking and the behavior that can result. And that’s just a few of them. cocaine. “It’s not real” is a losing strategy with someone for whom auditory hallucinations are as real as the music on your iPod is to you. normal pressure hydrocephalus. you can sympathize with even the most outlandish stories. “That must have felt horrible. don’t try to enter into the psychotic symptom. Alcohol is by far the most common substance-use cause of psychosis. to the question. cannabis. “Do you believe me?” respond “I believe you feel this way. Instead. and I want to help you with those feelings. not the alleged source. inhalants. request clarifications as needed.” Agree that the patient has a right to these feelings. Avoid directly confronting hallucinations or delusional thinking. Label this emotion—for example.” A reiteration of the original question might lead you to respond. For example. but when we encourage communication. “What message do you hear?” not “What did God say?” In trying to ascertain how firmly a patient holds an idea that may be delusional. however. we allow the patient to express fears and concerns that might otherwise have no outlet. Sedatives and alcohol are associated with psychosis during either intoxication or withdrawal. a great variety of drugs (street and prescription) can also be the culprit. to a patient who hears the voice of God. mock-exorcise a “demon” or wash away “bugs crawling on the skin. This could allow the patient the relief of communicating sensations that may have had no other outlet. a mistaken diagnosis can complicate a patient’s life for years to come. “I • • • • • • • • . Key into the patient’s experience. Later. ask open-ended questions. ask for a description of the experience (“Tell me exactly what you hear”). sad. schizophrenia patients are among the most difficult for trainees to work with. e. As with Danny. So. porphyria. The physician’s approach to patient and family Because psychosis lies far outside the life experience of most students.

” “Your doctor says…so we have to comply” puts you and the patient on the same side of nearly any issue. “Yes. “I’ll try my best to get you onto an open ward. anyone can become very sensitive and begin to interpret everyday events in a special way.g. I understand that you worry about the voices in the hallway. “I’ll be glad to speak with your doctor about more privileges. even if it is trivial. offer thanks and then go on to another topic.” Once the patient agrees to something (e. some of whom behave in unpredictable ways. which can seem confrontational.Psychosis 84 • • • wonder if there could be some other explanation…” or “I’m having trouble understanding what you’re telling me. we have all possible time intervals covered down .” “Why don’t people believe me when I say [the CIA taps my phone]?” is the sort of question you might well be asked. but I recognize how important it is to you. Establishing trust is hard enough without demonstrating that you are willing to go back on your word. It’s reasonable to respond with (“Why do you think it is?” or “What would you think I might say?”) For suspiciousness. physicians should be extra careful to project a calm and reassuring demeanor. Brief Psychosis Anyone who’s been paying close attention might have noticed a hole in the line-up: with schizophrenia and schizophreniform disorder. but it probably will have to wait until you are feeling less angry. Be careful what you promise. A psychotic patient is likely to pay scant attention to the rules and requests of someone who cannot even appreciate the fact of text messages sent by Elvis or Princess Di. but I suspect I’ll be rebuffed. further discussion of which might just cause the patient to reconsider. try to present it (usually. You don’t need to address that topic any more. never blow off depression and (especially) suicidal ideas.. perhaps during a ward meeting.” You may have to continually refocus the patient’s attention. resist the temptation to assert your authority. But let’s try to finish our discussion of your problems sleeping. Signal early for help.” And of course. something you can agree on. Finally. providing a basis for relationship. “It’s sure been a cold winter” is a statement you can make that puts the two of you on the same side. The warnings about safety apply strongly to psychotic patients. For example. Try to find shared ground. In responding to aggression. Sometimes this goes down better if it comes from other patients. offer a possible alternative explanation. and don’t fight. patients with clearcut schizophrenia become depressed and may commit suicide. talk quietly and try to avoid direct eye contact. An approach to aberrant behavior • • • • • • • For treatment refusal. taking medication). medication) as a chance for the patient to regain control over illness. and do your best to move out of the area—calmly but rapidly. “When under stress. because patients (and their relatives) can be quite confused and often frightened. ideas of reference and other delusional material. Regardless of the behavior. Don’t argue.

write to me—I’d love to hear. The person with the shared psychosis usually comes to medical attention only when the primary patient is identified. the primary case is the dominant individual in the home or partnership. Onset tends to be within the same age range as schizophrenia. Completed suicide is a particular risk in this group. observation may reveal the final diagnosis to be a psychotic mood disorder. originally as folie à deux (the madness of doubles. in the poorly understood. Sidebar: Violence and Mental Disorders The unhappy truth is. of which I’ve encountered only one in over 15. in all my years of practice. However. partly to escape the beatings from her stepfather. These patients may experience rapid shifts of intense affect. Consider two scenarios: At age 21. Over the years. though instances are recorded that involved three or more individuals—always one “primary case” who was delusional first. The wife would swear that this was happening in their home. but the leap we’d like to make to accurate predictions has included rather too many missteps. that’s covered. followed by others who come to share in the psychosis. she had repeatedly run away from home.Psychosis 85 to a month. and she had dropped out when she was 15 to drift in and out of juvenile hall. we’ve learned some of the factors that are associated with violent behavior. might even adduce evidence to prove it. These patients must have one or more of the classic symptoms: delusions. For example. At 16. the strength of this belief would gradually wane and her delusions would fade away without medication or other specific treatment. These people apparently become psychotic because they buy into the delusion of someone with whom they are intimately connected. don’t expect to encounter a lot of these people. Smart but unmotivated to study. once separated from her husband. too. her grades throughout school had been a series of Ds and Fs. Shared Psychosis And here is a truly fascinating condition. Often. If you do see a person who meets these criteria. and disorganized behavior (no negative symptoms). Brenda drank and was a good customer for the amphetamines she cooked in a lab she’d helped her boyfriend construct in his grandmother’s basement. and may be apparently precipitated by a stress. she stabbed and nearly killed another girl. let alone weeks or months into the future. hallucinations. after consuming alcohol and “other stuff” at a rave. This condition has been known for many years. or a psychosis due to a medical illness. I’ve never seen one. the wife of a schizophrenia patient begins to believe his delusion that the Catholic Church has installed spyware on his computer. If you ever encounter such a patient. However.000 psychiatric patients. such as childbirth. But what about patients whose psychotic illness has lasted just a couple of weeks? Well. or double insanity). disorganized speech. Brenda was released from custody when she turned 21. Her parole officer recently . or even whole families) are isolated socially. From age 11. death of a relative or some other trauma. psychiatrists are little better than anyone else at predicting violent acts accurately—it’s hard enough to foresee behavior within the next few hours or days. many of the pairs (or trios. rarely encountered brief psychotic disorder.

Psychosis noted that she’d resumed drinking, and that several times she’d threatened to “finish the job” on the girl she stabbed years ago. Brent, also 21, fell ill early in his junior year at university. Always a steady, earnest student, both Brent and his family were surprised at how quickly his grades tumbled once the voices he now heard began telling him he was the Devil. “Academically, he just seemed to wither away,” said his aunt, with whom he lived while attending school several hundred miles from where he grew up. After the first few weeks of the fall term, he gradually stopped going to class. He neglected his appearance and refused to go home for Christmas. By the end of April, he wouldn’t even leave the house. When questioned, Brent said that he had come to realize that he was the Antichrist, and through him the world would be destroyed. His aunt told the clinician that her husband kept a pistol in an unlocked desk drawer; she didn’t know, but she thought it might be loaded.

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Many clinicians might decide that Brent’s history of psychosis and the fact that he was young, male, and had apocalyptic delusions rendered him likely to commit a violent offense. However, over the years, traditional clinical methods have proven unreliable in assessing violence potential. A large part of the difficulty lies in the fact that studies of violence are often based on general population samples, whereas physicians want to know how likely a particular patient is to commit an act that will harm someone else. To answer this question, researchers have developed actuarial models that rely less on clinical information and judgment, more on data from records and demographics. Some of the findings are surprising. Diagnosis. We traditionally associate violence with a number of diagnoses—schizophrenia, mania, sociopathy, conduct disorder (in children and adolescents), intermittent explosive disorder, and substance use disorders (especially when a person is actually using drugs or alcohol). However, the overwhelming majority of mental patients do not perpetrate violence. In fact, a major Axis I mental disorder such as bipolar I disorder or schizophrenia (Brent’s diagnosis) carries a lower risk of violence than do some personality disorders. A number of physical brain diseases can also lead to violence—head injuries, seizure disorders, Alzheimer’s and other dementias, infections, cancer and other mass lesions, toxicity (including drug and alcohol), and metabolic conditions. The comorbid diagnosis of substance misuse is always important to watch for. Gender. Men are traditionally regarded as committing the major share of violence. However, among mental patients, women like Brenda are about as likely to perpetrate violence as men, though their victims may be less likely to require medical attention. Violence in women occurs most often in the home. Previous violence. A history of violent behavior is a traditionally strong predictor. Remarkably, learning about such a history doesn’t usually pose a problem: patients are often quite willing to admit to prior offenses. Brenda’s prior history of conviction for assault clearly demonstrated her potential. Abuse. Childhood physical (but not sexual) abuse is positively associated with later violence. Antisocial personality disorder. The risk of violence is greatly increased in patients with ASPD. Although we’d need more information to be sure, what we know so far about Brenda should alert us to the possibility of conduct disorder and ASPD. Hallucinations. Command hallucinations that order the person to commit violent acts increase the risk; other hallucinations are not related. Other delusions (Brent thought he was the Antichrist) do not predict violence.

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Anger and thoughts/fantasies of violence. Ideas of violence beget violent behavior. Brenda was clearly signaling her intentions. Age. The time of violence, like the time of love and procreation, is youth. No surprises here. In summary, the actuarial model predicts that violent mental patients will tend to be those who are young, hostile, misuse drugs, and have a history of previous violent behavior. And it would be Brenda, not Brent, who represents the greater risk. Numerous studies report that discharged mental patients are likely to perpetrate violence only if they use substances. Unfortunately, they are more likely than the general public to misuse substances. When mental patients do repeat violence, it is usually within a relatively short time after hospital discharge. Here’s a final, sobering thought: some of the most notorious violent patients in history would probably have slipped past the best of our current predictors: Prosenjit Poddar (who murdered Tatiana Tarasoff, eventually leading to the recognition of a duty to protect known as the Tarasoff principle); Mark David Chapman (who killed John Lennon); and John Hinckley, Jr. (who attempted to assassinate Ronald Reagan). Each of these individuals had had intense fantasies, but no prior history of violence. Even the best research and instruments can currently deliver no promises, only predictions. Table 6. Criteria for psychosis (DSM-IV simplified) Duration Symptoms
6 months or more Schizoaffective Schizophrenia disorder At least 2 of: Delusions Hallucinations Disorganized speech Disorganized behavior Negative symptoms At least 2 of: Hallucinations, Delusions, Disorganized speech, Disorganized behavior, Negative symptoms, plus Simultaneous major depressive, manic or mixed episode At least 2 of: Delusions Hallucinations Disorganized speech Disorganized behavior Negative symptoms

Disability/Severity
Material impairment in patient’s work, socialization, self-care

Exclusions
Mood disorder Schizoaffective Gen med condition Substance-related Developmental disorder Gen med condition Substance-related

1+ month of sx (less, if treated). For 2 weeks, delusions or hallucinations w/o prominent mood sx 1–6 months

Mood episode symptoms present during substantial part of active and residual portions of the illness

Schizophreniform psychosis

“With good prognostic features” if 2+ of: Psychosis starts w/in 4 wks of onset Confusion or perplexity Good premorbid social, work functioning Affect not flat, blunt

Mood disorder Schizoaffective Gen med condition Substance-related

Brief psychotic disorder

One day to one month, with full return to previous functioning level

1+ of: Delusions Hallucinations Disorganized speech Disorganized behavior Delusion is similar in content to the first person’s delusion

Mood disorder Schizophrenia Schizoaffective Gen med condition Substance-related Mood disorder Schizophrenia Schizoaffective Gen med condition Substance-related

Shared psychotic disorder

Begins after a close associate becomes delusional

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Review
When he was 17, Jason’s parents (and two other adults) took him to the hospital. Late at night, when he was alone, he had been hearing the voice of his Spanish teacher. Her voice, which seemed entirely real to him, told him (in Spanish) that he had been selected to be sacrificed. With increasing frequency, for nearly a year, he had heard the voice, and he was becoming more and more frightened. His mother heard him pacing his room at night, but when she asked what was wrong, he would shrug and silently turn away. The day he was admitted, she had entered his room to straighten up and found it “completely destroyed.” The shelves were bare; all their contents had been piled in front of the wardrobe door. His clothes had been dumped from the dresser and shredded with the scissors he had then used to inflict dozens of tiny wounds on his forearms. Sensitive and friendless as a little boy, Jason had never shown the slightest interest in other people. Instead, he developed such a passion for moths and butterflies that by the age of 13, he had collected several hundred varieties. Before becoming so ill, he had often studied the wonderful collection at the natural history museum. He even thought that he had discovered a new variety of Papilio polyxenes, the black swallowtail butterfly. However, he hadn’t chased a butterfly in weeks, and his only scientific activity had been talking into his portable tape recorder. His family life had been marked by the divorce of his parents several years earlier. Each of his parents had subsequent lovers—his mother’s current boyfriend lived in their home, but so did his father. An aunt had had a breakdown when she was in college and never recovered; she had lived with her parents until she died, an eccentric and lonely woman. Jason’s doctor started him on Haldol, which quieted the hallucinated voices and calmed his agitation, but a few weeks after leaving the hospital he stopped taking it. He told his mother that it made him feel “wired” and he didn’t need it anyway; he wasn’t sick. For several weeks he just seemed anxious and irritable, then he gradually became aware that his telephone conversations were being “intercepted,” and he thought that the museum curator was trying to steal his P. polyxenes. On his second hospital admission, the doctor asked whether he could be mistaken about the curator. Jason just gazed out the window. His appearance showed evidence of neglect. His jeans were stiff with dirt, and he needed a wash himself. He sat sullenly, arms folded across his chest. Later, his mother brought in his little tape recorder. On it, Jason’s voice said this: “I think I have developed a new construction of a P. polyxenes. This construction is built largely on a podel that mitigates its life force.” When asked about the word podel, he said that it was a model of a P. polyxenes. 1. 2. 3. 4. 5. Write out a complete differential diagnosis for Jason. [p 71] Which basic symptoms of psychosis did Jason have? [p 70] Which basic symptoms of psychosis did Jason lack? [p 70] What would be your best diagnosis? Justify your choice. [p 73] How would this change if Jason had been ill for only 3 months? [p 80]

) More recently. . Ian McEwen wrote a gripping portrayal of the disorder in Enduring Love. Outline your treatment recommendations for Jason. One resource that I can recommend is the movie version of A Beautiful Mind. Readily available on DVD. What indicators of risk for violence does Jason have? Which does he lack? [p 85] 9. To receive the diagnosis of schizoaffective disorder. I tend to look askance at most of these.Psychosis 89 6. Suppose Jason had had only delusions and no other psychotic symptoms—how might this have altered the course of his illness? [p 81] Further Learning There are an awful lot of books on Amazon written by people who claim to have recovered from schizophrenia. [p 77] 8. Quite a few years ago the movie Fatal Attraction starred Glenn Close in a virtuoso portrayal of a person who was obsessed with the belief that Michael Douglas’s character was in love with her—to the point that she arose from what appeared to be death in a bathtub of water to renew her attack. what would Jason’s symptoms have to be like? [p 79] 10. How would you describe Jason as a child? And how could this relate to his diagnosis as an adult? [p 73] 7. It’s a great read that in 2004 was also made into a motion picture. because I have trouble being sure that they were properly diagnosed in the first place. Popular writers do seem to have discovered delusional disorder. at least that form of it called erotomania. (Never mind that women with this disorder aren’t usually the one’s who are violent. It gives the viewer a really good feel for what it must be like to experience psychosis.

But problems arise when anxiety becomes too intense or lasts too long. it muddies our thinking and robs us of focus and alertness.Chapter 6 Anxiety and Panic In its many forms. nameless fear of death or—the unknown. All occur more frequently in women than men. Everyone feels some of these anxiety symptoms at one time or another. and behavioral effects—an uneasy sense of apprehension. which can produce a powerful urge to lash out or to run. anxiety is a little like food: sometimes it’s hard to judge how much is too much. trouble with breathing. instead of spurring us to run the race of our life or ace an exam. perhaps before a public performance or when confronting some other unpleasant task. but heredity alone can’t explain them: life’s events and circumstances also play powerful roles. normal reaction to a perceived threat. All anxiety disorders have in common one or more of the following features: Anxiety—an uneasy state of apprehension that exceeds any actual threat you may be facing Panic—acute anxiety accompanied by bodily symptoms such as racing heart. Anxiety can be felt as irritability or fear. heart palpitations or chest tightness. With a conservatively estimated 20% lifetime risk. it sharpens the senses to help us prepare for upcoming tests or performances. and it reminds us to stay on the right side of the law. and uncontrollable trembling Phobia—anxiety where you can pinpoint the cause. a decreased ability to concentrate with a nagging sense of unreality. So. Most anxiety disorders seem to run in families and have some genetic basis. Anxiety can also take the form of chronic worry. nausea and hyperventilation. a finding that has researchers worldwide scratching their heads. anxiety has emotional. anxiety is a natural. Then. physical. mental. moral codes. which exceeds any actual threat Stress—which causes anxiety (or fear) 90 . It is useful: it signals us to watch for possible danger. and professors. dry mouth or trouble swallowing. anxiety disorders are the most common of all mental disorders. as if by ruminating about the future we can sometimes control it. When brief and relatively mild.

Uncued attacks come out of the blue. True panic attacks can so flood the intellect that we cannot focus our attention. who said his health was good and minimized the problem. Winfield’s first panic attack had occurred about 5 years earlier when he was flying to Europe on vacation. personal disaster. The entire episode lasts less than half an hour. promotions or sex. patients will experience several of these symptoms and have a foreboding sense that some disaster is imminent. Some people have both types of attack. heart palpitations. he asks his brother a neighbor to go with him. The woman next to him kept pulling away “like she thought I was crazy. Symptoms and diagnosis Winfield’s symptoms include trouble breathing. Just the thought of attending a concert is enough to cause intense anxiety. They had just cleared the U. The complete list of panic attack symptoms is given in the footnote to Table 7a. Now age 31. During a typical panic attack. which was where he remained for most of a week. Lately. Severe panic attacks sometimes cause repeated trips to an urgent care center or emergency room.Anxiety and Panic 91 Panic Disorder and Agoraphobia The riveting anxiety of a panic attack creates a characteristic pattern of incapacitating physical symptoms.S. other people complain of faintness. or feelings of unreality. sweating. he expected that he might die or lose his mind. dizziness. it would be perfectly normal to feel these physiological symptoms. he would be trapped. tremor and fears of calamity. coastline when he suddenly felt he was about to suffocate. When he must shop for groceries.” “The Dow’s drop signals panic in the markets”) pales in comparison. His chest hurt. chest pain.” but a man sitting behind him suggested that he breathe into a paper bag. He mostly telecommutes to his job as an accountant. with no known precipitant. Again. hot and cold flashes. so he avoids crowded places and spends most of his time at home. especially when in a crowded place like a shopping mall or a football stadium. “everything seemed to be closing in” around him. his heart pounded. The next day. Some attacks are cued by a stressful event. even on issues so important as examinations. though it can seem a lot longer if you’re afraid that you are going crazy or your heart’s about to explode. However. but he cannot even go for a drive without experiencing severe anxiety. numbness or tingling of their hands. Winfield has had frequent attacks. When he arrived in Paris.” His head seemed to bob and spin. cued or uncued. and his hands trembled so that he couldn’t eat his meal. he consulted his general physician. He survived the trip with his face buried in an air sickness bag. venturing out only for meals and a quick trip to the Eiffel Tower. Everyday “panic” (“I panicked when I locked my keys in the car. If you were suddenly attacked by a dog or you realized your 2-year-old was missing from the backyard. such as seeing a spider or hearing the sound of gunfire. repeated severe panic attacks. he felt overwhelming anxiety whenever he left his hotel room. Typical panic attacks start suddenly and build rapidly to a peak. interfere with social and interpersonal life—a student may . and he thought he was on the verge of “a true. After he returned home he had no recurrences for several months until one evening at a concert he realized that he was sitting in the middle of the second row: once the music started.

physicians have often regarded mitral valve prolapse as the cause for panic attacks. and amphetamines. isolated panic attacks may be just one more youthful rite of passage. agoraphobia often seems to start with a panic attack. Following is a reasonably complete listing of the conditions you might consider in a person who is experiencing symptoms of panic: . certain types of heart disease. when the two coexist. however. For weeks. For some. And like Winfield. PD remains the most likely diagnosis for recurrent panic attacks. or where help might not be available if anxiety symptoms develop. buses. low blood sugar. Attacks can also occur with the excessive use of certain drugs. bridges. those whose only complaint is agoraphobia just stay home. the fear of being in a situation from which escape isn’t possible. theaters and travel away from home. you can see exactly how the criteria differ. Agoraphobia without actual panic attacks may be more common than we once thought. a spouse may seek divorce. chronic lung problems such as emphysema. But when panic attacks are repeated over and over. including caffeine. they travel only when escorted by a trusted companion. It isn’t unusual to awaken at night with them. or loss of bladder control. Panic attacks are rarely caused by thyroid disease. When out and about. and they may think they are going crazy. if they have begun only recently. but one attack doesn’t always mean there will be more. affecting perhaps 3% of the general American population. People will do nearly anything to avoid them. would worry anyone. More recently. The prospect of more attacks occurring any time. formal diagnosis. A medical condition is a somewhat more likely cause of panic attacks if they begin after the age of 30. At a minimum. and PD with agoraphobia. Possibly. the first step is to rule out medical illness as their source. The agora is a Greek marketplace. agoraphobia. when it comes to making the final. marijuana. the choices are panic disorder (PD). these people run a severe risk of becoming housebound. we’ve concluded that. or if there are unusual symptoms such as trouble walking. In Table 7a. Even to them. a panic attack occurs that is subsequently forgotten.Anxiety and Panic 92 find it impossible to move out of the parental home. but people with agoraphobia are likely to avoid any venue where they’d have difficulty making a speedy exit. Differential diagnosis Anyone who has ever experienced a panic attack will feel that something is wrong. these people begin to generalize fear to other situations that involve being away from home. the breathlessness and weakness can force the person to lie down or otherwise interrupt the normal routine. including malls. In any event. However. the fear seems irrational. so fearful are they to leave home that they simply don’t—or else. or pheochromocytoma. In the past. both should be diagnosed. Like Winfield. Many young people have a few episodes of panic without ever developing a lasting pattern of repeated attacks. unexpected and unexplained. which can occur occasionally or many times a week. they may come in daily waves—then calm for months. infections such as pneumonia and Lyme disease. only those with panic come in for treatment. an altered level of consciousness. Agoraphobia: often added to panic Panic attacks often occur in agoraphobia.

However. though many clinicians also believe that we learn to have panic attacks through behavioral conditioning. beginning with some education. for the simple reason that it could exacerbate some conditions (asthma. Major depression strikes a large proportion of PD patients (over half in some studies). He was instructed to avoid using nicotine and caffeine. heart attacks) that entail shortness of breath. experts now recommend against it. obsessive-compulsive disorder (OCD) and posttraumatic stress disorder (PTSD).Anxiety and Panic 93 Anxiety due to substance use Anxiety due to a medical condition Major depression Specific phobia Social phobia PTSD OCD Anorexia nervosa Epidemiology. affecting perhaps 3% of all adults. and comorbidity Women are twice as susceptible as men to panic disorder. Other anxiety disorders often accompany panic disorder. but no one really knows for sure. social phobia. such as depression. This . the SSRI citalopram (Celexa). which could worsen his panic attacks. many also turn to the use of drugs or alcohol. He started taking an antidepressant. Several weeks after beginning his treatment. but a wellknown condition that thousands of others had successfully conquered. In their quest for relief. We do know that no racial or ethnic group is immune. indeed. often the mood disorder begins first. Nonetheless. for actual panic attacks. but no one knows why. He felt reassured when he learned that he didn’t have a serious physical disease. and that it is more common than you might expect. Treating panic and agoraphobia The folk remedy of breathing into a paper bag. Panic disorder is present in at least half the people with agoraphobia. increasing by 5 mg/day each week until he got to 20 mg/day. reassurance from a physician could be all the treatment some patients need to prevent further episodes. including generalized anxiety disorder (GAD). which forces rebreathing of carbon dioxide. that panic disorder usually begins in the late teens or 20s. the recommended treatment will depend on the severity of attacks and the presence of other disorders. can relieve symptoms of panic. Some people try to control panicky feelings by overusing alcohol or drugs. Winfield’s doctor approached his PD from several angles. Their coincidence is frequent enough that it is important to look for mood disorder in any patient who presents with any anxiety disorder. For actual PD. It runs in families and is at least partly genetic. at the very low dose of 5 mg/day. Still others implicate loss of parents in childhood and loss of important adult relationships as possible psychodynamic causes. etiology. and depression and other anxiety disorders are also common with agoraphobia. he noticed that he hadn’t had a panic attack for days. prescribed or otherwise.

After the first couple of sessions. fearing another attack if he went out. Winfield went out each day by himself. no one knows for sure just how long treatment should last. he could go shopping alone and attend theatrical performances once again. However. The acute phase of treatment should last about 12 weeks. which work well for panic disorder and produce relatively few side effects. or a tricyclic antidepressant such as desipramine (Norpramin). Cognitive-behavioral therapy (CBT) specifically targeted at panic symptoms is at least as effective as medication. only alprazolam (Xanax) has good evidence for effectiveness at reasonable doses. The risk of tardive dyskinesia should completely eliminate traditional antipsychotics. which can initially exacerbate agitation. Relapses aren’t uncommon. The period of hypersensitivity usually lasts a week or two. improved morale. Of the benzodiazepines. If the first SSRI fails. This time. Once improved. who urged him to join a group of agoraphobia patients for direct exposure treatment. As with so many other mental disorders. but some people have trouble stopping it. Treating agoraphobia Within a few weeks. In addition to the group therapy sessions. anyone who cannot use the exposure approach may derive help from other treatments. even though it initially caused him to feel shaky and frightened all over again. Winfield’s panic attacks had subsided a lot but. including . the most frequent cause of non-response is taking too little medication. Other medicines that have been used to treat panic disorder are more problematic. The antianxiety agent buspirone (BuSpar) is ineffective in treating panic. they might add a beta blocker such as propranolol (Inderal). Even if medications block the actual panic attacks. By the end. They made lists of what bothered them the most and ranked the items in order of increasing anxiety. which can provide help with symptom control right away and later help bridge the period of drug discontinuation. Monoamine oxidase inhibitors are usually reserved for those who don’t respond to other drugs. For lingering anxiety symptoms. venlafaxine (Effexor). he remained nearly housebound. But PD patients tend to be sensitive to the side effects of antidepressants. By the end of these sessions. Most people who are treated with exposure therapy experience reduced anxiety. but the others continued for 12 weeks. That’s why Winfield started with less than half the usual dose. and the effect may last longer. try a different one. it was as if they had “packed their bags one night and sneaked away. they indicate restarting medication.Anxiety and Panic wouldn’t have been especially noteworthy—he had sometimes gone for weeks at a time without one—but always before. one group member reported marked improvement and dropped out. they had seemed to tail off gradually. One behavioral component is to retrain breathing. and greater ability to form relationships and pursue work and leisure interests. Then they went out in small groups to face their fears. so as to control the hyperventilation that occurs with panic attacks. patients often continue to experience anticipatory anxiety and avoidance behavior. That’s why many physicians also recommend psychotherapy. most had improved.” 94 Most physicians would probably recommend one of the SSRIs. so most patients should probably continue the antidepressant for 12–18 months before attempting to taper it. as he told his therapist. after which the dose can be gradually increased until symptoms remit. At that point he was referred to a therapist.

such as when a hard workout immediately precedes a heart attack or job loss leads to depression and anxiety. Prognosis is better if symptoms have been present for just a short time—another excellent reason to begin treatment as soon as the diagnosis has been made. many follow an on-off pattern of symptoms for years. you’ll find a few suggestions for keeping a lid on anxiety. And when our best efforts at prevention fail (as they inevitably will. talking with friends. However.Anxiety and Panic cognitive-behavioral therapy. Of course. For each problem you face. severe illness. Self-medication with drugs or alcohol or refusal to leave home can have serious implications for work and social life. (4) match your tasks to the block available (maximizes efficiency). we often have little control over many of life’s most stressful events—the death of a relative. assertiveness training. being downsized in a recession and. environmental factors can modulate the effect of stress—someone with no money in the bank may feel more keenly the loss of a job. sometimes. taking a shower or warm bath. and relaxation. meditation. reading for pleasure. but many people without diagnosable mental disorders are affected by stress. These intertwining relationships between stress and mental disorder provide one motivation to reduce stress in our lives. • • .” The feeling that you have no options creates a sense of helplessness and anxiety. drugs are not generally indicated for agoraphobia. putting the most important tasks first. Interrupt your usual routine with something you don’t have to do—listening to music. Giving yourself time to pursue a pleasurable activity is a reward that can quickly recharge your batteries. but anxiety is also a symptom of stress. They may experience frequent attacks for weeks on end. Practice time management. It might go something like this: There’s a complicated relationship between anxiety and stress: stress can cause anxiety (and other illnesses. Having each source of stress written out in black and white can help give you a sense that you can get your arms around your burdens. Well over half those who complete treatment are recovered or very much improved. both mental and physical). Other than managing associated panic attacks. There is powerful evidence for some of these causal relationships. Only about a quarter still have symptoms severe enough to require a trial with other therapies. from time to time). (2) estimate the time needed for each (add about 10% to each as a cushion). be sure to include all your possible solutions. • • Make a list of all your tasks. pregnancy. Even so. Sidebar: Talking to Patients About Stress “What can I do about all the stress I’m having?” is a question psychiatrists and other doctors are likely to hear. It helps somewhat to have a good suggestion or two ready. yielding to weeks or months with essentially no episodes at all. (3) search your calendar for blocks of time for each task. it helps more to have an organized list of answers. 95 Course of illness Although most people seek treatment soon after the first attack—panic is just too uncomfortable to tolerate—left untreated. there are steps you can take to help reduce the toll stress takes on your health and happiness. In simple terms this means: (1) prioritize your list. even if your principal alternative is “do nothing.

When confronted with the feared stimulus. I worry that too few doctors bother. People feel perkier when they are well-hydrated. Specific Phobias Agoraphobia is just one of many phobias. so drink plenty of liquids (but keep alcohol. well-balanced meals each day. embarrassment. Nothing helps you through tough times like knowing what to do. and communing with nature (even in an urban setting) helps maintain perspective. Aunt Josephine. hardly any of which are used anymore. Exercise for at least an hour—preferably more—each week. establish routines (but brace yourself for change. the two names you’ll still encounter are acrophobia (fear of heights) and claustrophobia (being closed in). without the physical symptoms typical of panic attacks. perhaps when it only creeps into consciousness. Besides agoraphobia. or dentists. Studies show that just talking to a patient about such matters as diet and smoking can help them gain control over weight and nicotine. The fear is normal if a poisonous spider crawls onto your pillow. people can develop a fear of just about anything (Lemony Snicket’s character. had a morbid fear of real estate agents).Anxiety and Panic • • • • • • • • • • 96 Even with just seconds available. but a full-blown panic attack whenever crossing a bridge— isn’t. Anticipating harm. the threat is something you can identify—such as snakes.” Spend time out of doors. Nothing stresses the system like “pulling an all-nighter. coffee. We’ll cover the second of these later (page 107). Ventilate your frustrations to anyone who will listen. think about something pleasurable you have done lately or would like to do. Daylight improves mood. But if you encounter a “Daddy Long Legs” on a wall. people are diagnosed as having one of three types of phobia: specific. When imagination makes something benign seem so ominous that fear significantly restricts their behavior. Practice regular breathing exercises. There are over 250 of these. people may respond with a panic attack. Many years ago. when it’s needed). but avoid hyperventilating. the person becomes frightened the moment the feared thing appears. Symptoms and diagnosis With phobias. social. though it could also be just a feeling of intense anxiety or dread. Keep regular hours. and other psychoactive beverages to a minimum). and agoraphobia. In fact. the general definition of which is a fear of some situation or object that far exceeds any real threat. Eat several small. and try not to discuss work at mealtime. Avoid eating at your desk. before we had effective treatments for phobias. heights. To feel anxiety if trapped alone in an underground cavern is reasonable. Specific phobias are what most people associate with the term “phobia”—when someone needs comfort during a thunderstorm or dissolves into tears upon spying a mouse. Some people have . about all mental health professionals could do was to pretty them up with Greek or Latin names. tea. or other dire consequences. but share your triumphs with someone you love. it isn’t normal to have a panic attack and refuse ever again to enter the basement. fresh air is bracing.

her heart “banged along something fierce” and sometimes skipped beats. in children. fear of clowns or other costumed characters. Whenever she stopped to think about an upcoming trip. other examples are riding in elevators and driving across bridges. She had also tried several medications and self-hypnosis.Anxiety and Panic multiple phobias. A few refuse to fly for any reason. for example. Those who are afraid of heights visualize a fall.” Terrifying thoughts about crashing or being hijacked kept her from concentrating on her work. Her anxious thoughts would come in waves and increase over several days until they peaked on the day of her trip. heights. conditions of the natural environment (thunderstorms. Andrea seemed to be heading in that direction. Andrea’s fear of flying started on a return flight from a European meeting. Rather common. she would feel terribly anxious. her misery grew with every business trip. and injury or blood (needles. which are usually of the same type. Andrea would be perfectly happy to be near an airplane. you can always go by car and avoid visiting other continents. She had never failed to complete a flight. and tunnels. creating problems at work or in their personal or social lives. and out of control. fear of flying is one of the “situation phobias”. such as snakes and spiders. for example. Many people don’t fear the thing itself but the imagined outcome. while landing. Once. these two categories belong at the top of every differential. those with spider phobia worry they’ll be bitten. For example. I don’t think I can survive this way. A few other phobias are harder to classify—the fear of getting sick. but it didn’t seem to help. she had “a clear vision” that they would be caught in a wind shear and crash. Even then. but it required an almost superhuman force of will. Differential diagnosis Anxiety due to substance use* Anxiety due to a medical condition* Major depression Panic disorder Agoraphobia Social phobia PTSD Although specific phobias are not usually associated with substance misuse or with physical illnesses. composer Richard Rogers feared almost anything having to do with travel. dizzy. visits to the doctor). Besides situations. Some people feel only mildly nervous. others call themselves “white-knuckle flyers” who will travel by plane only as a last resort. * . water). “but job or no job. fear of flying presents a spectrum of distress. if she knew she didn’t have to board it. she had taken a course in which she was encouraged to meditate and visualize successful flying.” 97 As with other phobias. Although she continued to fly. what she feared was that a plane would crash with her on it. High winds buffeted the plane. she had trouble breathing and felt “weak. Many people have more than one phobia. Beginning several days before each flight. it may only interfere with vacation plans—after all. but she remained fearful.” she said. elevators. A woman who feared crossing bridges worried that an earthquake would strike while she was on one and hurl her into the chasm below. people can have three other classes of phobia: animals. These fears are not only excessive but persistent and unreasonable (logic doesn’t resolve them). including bridges. or. “I know it’s way out of proportion.

Treating specific phobias Many people successfully cope with a specific phobia by just ignoring it. most patients seek treatment because of something else entirely—often. but once attained. which are hard to schedule. but many experts today will tell you that they probably come about when something acts as a trigger in a person with genetic vulnerability. crossing bridges. pausing at each step long enough to allow any anxiety symptoms to climax and subside. and comorbidity Phobias often begin in childhood or the teen years and almost always start by the age of 25. Many sessions might be necessary before the patient could comfortably take elevator trips alone to the top of tall buildings. the patient imagines scenes progressively . With systematic desensitization. That isn’t hard to do if it is mild enough. with the door open. and Oregonians don’t have to endure many thunderstorms. that mastery would probably be permanent. but most others begin in adolescence or early adulthood. the intensity of reaction may be influenced by degree of physical proximity to the feared object and how hard it is to get out of the way. A fairly strong hereditary component has been identified. Several circumstances can set up that trigger: direct experience with something that subsequently causes fearfulness (a child being terrified and alone in a thunderstorm. then to the third floor. and substance misuse. certain phobias demand resolution—for example. been warned repeatedly to beware certain objects. even hearing about someone who has been struck by lightning. both patient and therapist might step inside. also called exposure in vivo. but then. anyway). they are more common in women. For example. depending on the feared stimulus. for example). been confronted by an animal. When a subsequent lightning storm pulls the trigger. Unless treated. or been trapped in situations such as a small room. Riding to the second floor would be the next logical advance. city dwellers don’t meet many snakes (of the sort that slither. affecting perhaps 10% of us at one time or another. However. Animal phobias typically begin in childhood. seeing someone else react fearfully to storms.” Living someplace where you won’t encounter the stimulus is another coping strategy. They are more likely to occur in people who have witnessed trauma. Next. These can begin suddenly or gradually. Specific phobias are common. The most efficient (if traumatic) treatment would be direct exposure. It isn’t practical for thunderstorms. most are likely to continue indefinitely. Commonly comorbid conditions include other anxiety disorders. etiology. Direct exposure is also useful for fears of driving. In fact. and the therapist’s judgment.Anxiety and Panic OCD Anorexia nervosa 98 Epidemiology. and other specific phobias. the person who lives or works in a skyscraper and is afraid to ride an elevator above the second floor. A therapist might at first walk the patient to an elevator in a three-story building and just stand there talking for whatever time it takes for the anticipatory anxiety to subside. most clinicians probably wouldn’t dignify it with the term “phobia. a comorbid condition. Then. then intensify. the patient’s willingness. mood disorders. CBT and other techniques can be used.

and lightheadedness. allowing painless penetration) has worked very well for some patients. I couldn’t have physically gotten up to make a speech. there is more to fear than fear itself. Gordon started an antidepressant at 24 when he became clinically depressed. He had first noted this problem years ago in speech class. meeting anyone new. Iontophoresis (a $400 gizmo that draws a local anesthetic into the skin. “Even if I could have spoken. If relatively mild. but some people feel so uncomfortable in social situations that they dread leaving home. and his muscles twitched and he shook so hard he felt glued to his chair. No one knows just why some people respond so strongly to the prospect of a needle stick. years later. breathing slowly to prevent hyperventilation may also help. he stayed in bed that day. Occasionally. He was supposed to debate a few days later but.” he admitted. Although some people are helped by systematic desensitization. terribly self-conscious. Although his mood improved dramatically. Special Case: A Needling Anxiety Medical personnel especially need to know about fear of needles. Social Phobia Shyness and stage fright plague many of us.” he told his doctor. drugs are hardly ever a useful main treatment for specific phobias. they don’t get the usual adrenaline surge. nausea. because . tolerance for all aspects of the feared stimulus is achieved. The very thought of getting up in front of the class dried his tongue like a flannel cloth. 5% or more of Americans avoid essential care because of it. a low-dose benzodiazepine or a beta blocker such as propranolol might be useful to reduce anxiety right at the start of exposure treatments. stamp collecting. perhaps after many sessions. it should only be undertaken in or near a doctor’s office. When people with needle phobia encounter needles. the loss of blood pressure leads to a heart attack or a fatal arrhythmia. Other social situations began to cause Gordon terrible anxiety. The consequences can be dire: the medical literature reports death in a score of patients. However. Rubbing a local anesthetic cream onto the spot a few minutes before the needle stick can reduce pain and anticipatory anxiety. sometimes they faint. with sweating. or speaking with anyone but close relatives. heart rate slows and blood vessels relax in their extremities. A number of approaches to needle phobia are currently used. formal introduction made him blush or stammer—he eventually took a job writing ad copy so he could work in a cubicle and not meet people. which affects a person’s physiology atypically. He couldn’t utter a word. where medical help can be quickly available. He did well on all the tests but earned only a C-minus in the class because he hadn’t given any speeches. In the case of needle phobia. he noticed that he had started blushing again. “The grade was a gift. Some people find relief in antianxiety drugs taken before a procedure. lying down with legs elevated when having an injection or blood drawn may prevent fainting. He stopped attending football games. Other than managing associated panic attacks. He was supposed to give a 5-minute talk about his hobby.Anxiety and Panic 99 more anxiety-provoking until at last. yielding a falling blood pressure. Even a simple. when he was only 16. Its physiological underpinnings and the fact that it seems to run strongly in families suggest that this condition is quite different from other specific phobias. Rather.

* . which can grow into a full-blown panic attack.” and may become huffy at the suggestion that it is anything like a regular phobia. a third can’t go to a party for fear of appearing an idiot on the dance floor.” Gordon tried to be out of the office when she came around. but I’m afraid I’ll look like a nerd. tremors. The common thread is a fear of doing something that will prove acutely embarrassing. So. The patient knows that these fears are irrational and hates the low self-esteem that follows such a social encounter. Of course. He liked women and wanted to date. Indeed. you harshly judge your own social performances and view others in the same situation as being more capable than you. and may even have origins different from other types of social anxiety. Typically. • However.” Symptoms and diagnosis of social phobia Social anxiety* patients are withdrawn and shy with strangers. they avoid situations where they must socialize—which can make them seem standoffish or elite. • Of course. is relatively rare. Some blush or avoid eye contact. These experiences cause far more distress and disability than garden-variety shyness. there is the activity itself. these anxiety symptoms only lead to further embarrassment. people with social phobia often feel as though all eyes are trained on them to detect their smallest mistakes. or at least the perception that you perform poorly.) Fear of public speaking (“mike fright”) is the most common of these social anxieties. sometimes called paruresis. If you have social phobia. They experience their distress most acutely with strangers. The result is poor performance. but the thought of asking someone out made his knees buckle. Although they like other people and want to be with them. the presence of others induces marked physical and emotional symptoms such as palpitations. perspiration. though the symptoms may constitute only nonspecific anxiety. fearfulness. (Gordon’s discomfort with urinating in a public restroom. he’d avoid eye contact so he wouldn’t get trapped into making small talk. One woman likened her social phobia to wearing a sheer dress that barely concealed her nakedness yet offered neither warmth nor protection from the gaze of others. or shy bladder syndrome. Some patients and clinicians cling to the older term “social anxiety disorder. which always left him feeling ignorant and flustered. one person may feel disgraced in a business meeting. He was especially leery of his boss. so as not to appear dull or dumb. even writing when others are watching. eating in restaurants. and poor concentration—the very stuff of panic attacks. though he admitted that she was “a very nice person. using a telephone or public restroom. other situations include meeting people.Anxiety and Panic 100 he knew he’d have to use a urinal when other men were waiting behind him. we wouldn’t diagnose social phobia unless it materially impairs the individual’s life or causes a great deal of distress. another is intentionally late for a new course in school rather than meet new classmates. though some anticipate danger in every social situation. “I know this is stupid. and may not speak up in groups. If he ever met someone he knew from work. just the anticipation of the activity can generate automatic thoughts (“I’ll look like a complete idiot”) that breed fear. The anxiety of social phobia is attached to three points of behavior. these patients are highly self-critical and have low self-esteem. Like Gordon. The feared situation causes intense anxiety.

like Gordon. Being with people is what bothers the person with social phobia. A second issue of differential diagnosis: the criteria for avoidant personality and social anxiety overlap to the extent that many patients with one diagnosis have both. 80% a decade later. One in five abuses alcohol. does so only with much anxiety and later worries about the “performance. though occasionally an embarrassing social event abruptly precipitates it. lifetime prevalence is around 5%. Its onset is usually in adolescence or young adulthood—50% by age 11. you may wonder how to distinguish them. it tends to develop slowly. social phobia is the third most common mental disorder. Some sort of genetically transmissible trait such as low extraversion may make people susceptible to social anxiety (and other) disorders. Those with agoraphobia aren’t afraid of people. Two studies have reported a strong association between social phobia and premature ejaculation (the social phobia comes first). and by fMRI data. Social phobia patients also tend to have other fears: about half have agoraphobia. Differential diagnosis Anxiety due to substance use Anxiety due to a medical condition Major depression Panic disorder Agoraphobia Specific phobia “Normal” shyness Body dysmorphic disorder OCD Avoidant personality disorder Epidemiology. and comorbidity Behind major depression and alcohol dependence. 60% have specific phobias. no one knows exactly what sets it off. they just want to avoid places where there are a lot of them. Once begun. as well as the presence of other disorders. Treating social phobia A patient’s treatment plan will depend on the severity and extent of the social phobia. etiology. . upon speaking. depending on the study. Someone who cannot avoid the activity entirely may try to blend in with the crowd or. though it often runs in families. which find that these patients have reduced dopamine receptor sites and transporter binding.” Because both social phobia and agoraphobia are associated with places where people meet. The neurotransmitter dopamine may play a role in determining social phobias—as suggested by response to MAOIs. though perhaps just one at a time. one Norwegian study found a common genetic influence for social phobia and avoidant personality disorder. Indeed. you should probably use both drug treatment and psychotherapy. one in six has major depression.Anxiety and Panic • 101 And that generates the third point: Avoidance to reduce the anxiety. possibly more. Parkinson’s patients have elevated rates of social anxiety disorder. For someone who fears many different social encounters. As with other phobias. perhaps to combat the anxiety and. the former may ultimately be deleted from the diagnostic manual. which act on dopamine.

though it may take up to 90 mg/day for 6 weeks or longer to reach full benefit. He learned to replace his automatic “I’d look like a nerd” response with “I’d feel nervous. but that if someone didn’t complete a homework assignment. Though double-blind studies have shown that monoamine oxidase inhibitors (MAOIs) are the most effective medication. phenelzine (Nardil). For those who do use. say. ondansetron (Zofran) works to prevent vomiting. such as the belief that everyone could see how anxious he was. others. phobic avoidance becomes a way of life. he and the other group members did some role playing and practiced initiating conversations and making small talk. they experience severe anticipatory anxiety when they must confront that special fear. for them. the SSRIs work just fine. the response rate is over 50%. the psychotherapy most often used. On paroxetine (Paxil). advanced education. Untreated. Onset after age 11. and absence of other psychiatric conditions all favor a good outcome. For nausea or fear of vomiting. The countless people whose only difficulty is performing in public or giving a speech may find a beta blocking agent such as propranolol very useful. Becoming depressed was luckier than Gordon realized. it just meant that the assignment was too advanced and needed to be adjusted. perhaps depressed and alcoholic. Some members joined Toastmasters.” To increase comfort in social situations. Even some professional speakers and performers routinely use these drugs to reduce performance anxiety. they are more likely to remain isolated and unmarried. because it got him into treatment— way under half of those with social phobia ever seek treatment. Though there is little risk that such use will interfere with performance. the patient should avoid hidden surprises (such as excessive drowsiness) by trying a dose several days before the chips are down. Those who fear most social situations and feel comfortable only with close friends and family are said to have “generalized social phobia”. just long enough to get started with CBT. avoidable social situations. but it should be reduced to a manageable level. their potential for side effects and the diet they require usually put them out of the running for first choice. Some people need medication long-term. The therapist pointed out that a group approach allows the anxiety to be addressed in a social context. with limited capacity for work and interpersonal relationships. Gordon discovered that the group could provide a model for his own behavior. making short speeches at dinner or reading stories to friends. most social phobia patients will improve. With available treatments. but also acknowledged that some patients need greater privacy when working on their social skills. It also provided feedback about some of his erroneous thinking. Course of illness Although some people get along rather well overall because they fear only specific. Gordon felt especially successful when he invited a woman in his group out for lunch. . Their anxiety may not be completely eliminated. Between therapy sessions. they were to practice on their own what they had learned during role playing. but I could still ask a question. and all were encouraged to consolidate their gains with homework—for example. The group leader said that real-life practice is essential to the treatment. his depression had largely remitted and he felt less panicky at the thought of group CBT.Anxiety and Panic 102 For many with social phobia.

A healthy bank balance and stable job are no shield against worry about poverty. he felt so agitated that he literally could not sit still. so a lot of research remains to be done. they may worry about how well they do with them and whether they can keep it up. difficulty concentrating. Most days he noticed the knotted muscles in his neck. “It’s all I ever accomplish. If there is another anxiety disorder. • A typical GAD patient worries about many things—job performance. when he was still in college. Although they usually maintain a normal work. he had two important things to worry about—finishing his thesis and finding a job. As one man put it. though some people fret about world hunger and the risk of earthquakes. school and social life. school grades. paying the rent. irritability. he would stay up writing and revising until nearly midnight. For example. Struggling to finish his senior thesis in psychology. but the worry itself. Of these. The worries do not occur solely in the context of another mental disorder. though the dominant focus may change from time to time. The pattern of worrying typically lasts for years. GAD worries will go far beyond those normally associated with it. “Now I’m worried about keeping my job.” he later told his therapist. He had first been bothered by daytime sleepiness the year before. that hadn’t stopped the worrying. • • GAD patients worry much of the time. the tension mounting. Most of these worries will be personal. A year earlier. GAD is always accompanied by physical symptoms that include restlessness. he found it nearly impossible to concentrate on anything else.” Worries keep them awake until long after bedtime or awaken them in the middle of the night. and trouble sleeping. The third characteristic is the one that must not be present: there is no specific focus. the increased muscle tension is probably the most specific. He had tried positive thinking and meditation. finances. Symptoms and diagnosis GAD has been used as a diagnosis for a little over 30 years. but when his mind seized on a worry. children’s health. fatigue. These worries are hard to control and extremely durable. he would lie awake for several hours. relationship with a lover—even such mundane matters as dry rot and leaky windows. Last year seems like the good old days. muscle tension. “I just couldn’t seem to turn off the worrying. Even then. A patient with panic disorder will have GAD worries in addition to the possibility of having future panic attacks. those who also have a phobia will worry about many problems in addition to spiders or eating in public. as is often the case. and the economy. Though he had managed to accomplish both. . but most patients have several physical symptoms. at its worst. and one that must not.Anxiety and Panic 103 Generalized Anxiety Disorder Lyman complained that he kept falling asleep at work. typically persisting despite abundant evidence that they won’t come true.” The worry caused him to feel tense. There are three important elements to this diagnosis—two that must be present. The problem isn’t what the GAD patient worries about. saving for retirement.

Treating generalized anxiety disorder Chronic worriers have typically been called “worrywarts” and advised to loosen up. and they very much want to combat them. job security or dental appointments. If you need more antianxiety ammunition than the antidepressants can muster. duloxetine (Cymbalta). symptoms serious enough to produce intolerable physical or mental symptoms or to interfere with normal activities suggest the addition of drug treatment. Of course.Anxiety and Panic 104 Of course. It may get worse when the person is under stress. and one study found that patients maintained . Such worries are expected. though women are more susceptible than men. Differential diagnosis Anxiety due to substance use Anxiety due to a medical condition Major depression Somatization disorder Panic disorder Social phobia OCD “Normal” worry Epidemiology. etiology. often related to a specific situation: My mom is sick in the hospital—will she pull through? You excel in the basic sciences. producing such physical symptoms and distress that we cannot function well in our jobs and personal relationships. Two psychotherapeutic formats have been about equally successful: progressive relaxation and CBT. four of which have now been FDA approved for treating GAD: venlafaxine. around 5% of the general population will experience GAD. though it typically goes undiagnosed until much later. In addition to the usual associated anxiety disorders (such as PD and phobias) patients with GAD often have major depression. especially if the worries fall into the GAD pattern. as long as they don’t take over our lives. In fact. and comorbidity Lifetime. There may also be physical conditions we associate with stress. patients usually realize that their worries are excessive. and yet be perfectly normal. some women report more GAD symptoms before their menstrual periods. most of us probably worry excessively at some time or other. but will that success translate to clinical courses? We can worry about weddings or dinner parties. Some clinicians remain unsure whether GAD is a genuine clinical entity—perhaps it only indicates a basic trait of anxiety. Substance abuse is also sometimes an associated problem. it isn’t that simple. Antidepressants have been shown to help the most. It’s reasonable to start with an approach that can create permanent change. GAD is no respecter of race or gender. with the GAD coming first. GAD runs in families and probably has a genetic diathesis. such as headaches and irritable bowel syndrome. which often begins in childhood or adolescence. However. buspirone produces less sedation than the benzodiazepines. Like most other anxiety disorders. However. The prevalence rate increases with advancing age to peak after 40. escitalopram (Lexapro) and paroxetine. As with other anxiety disorders. worrying and anxiety don’t always mean a diagnosis of GAD.

a master sergeant had raped her in the mess hall . perhaps with exacerbations and remissions. the squeal of tires or honk of a horn brings back. As far back as the American Civil War. just for an instant. Posttraumatic Stress Disorder If you’ve ever had a minor car accident. Lyman began treatment with a form of CBT in which he was encouraged to practice progressive relaxation and to restructure the negative thoughts he was constantly having. though half or more of affected people have only mild or moderate symptoms. especially if they are severe. several studies have found that patients who complete these treatments maintain their gains for many months. Because GAD patients often have depression as a more pressing problem. All benzodiazepines are about equally effective. Any substance use problems must be addressed forthrightly. similar symptoms were identified in combat soldiers. but most patients will improve. you’ve probably had some of these physical reactions: your heart beats fast. you can hardly breathe. so this time he started on buspirone 5 mg three times a day and gradually increased the dose to 40 mg daily. well. “Now I mainly worry how to pay for treatment. including airplane crashes. buspirone won’t start working for at least a couple of weeks. While she was on duty at a military base in Germany. Earlier names included “shell shock” and “battle fatigue. within 2 months he could joke. Symptoms and diagnosis Several months after her Army discharge.” He had tried an antidepressant a couple of years earlier and didn’t like the way it made him feel. the antidepressant will often be effective for both conditions.” Course of illness To be candid. Aretta entered a VA hospital. abductions. he learned he was supposed to replace his irrational thought “I have too many problems to live” with “Oh.Anxiety and Panic 105 their improvement better with it than with benzodiazepines. floods. Several weeks later he reported that he was feeling calmer and more confident. However. after several weeks with little progress. here comes one of those pesky worries again. you’re too weak to stand. Even with treatment. Lyman’s improvement may have been somewhat better than that of many patients. They have developed posttraumatic stress disorder (PTSD). Some people who survive severe trauma develop symptoms that last much longer—perhaps even a lifetime—and their symptoms are far worse than the aftermath of your car wreck.” Although he initially refused medication. so a benzodiazepine may be needed short term. Untreated. he finally asked for something “to take the edge off. GAD is still too poorly studied to have confidence in predicting outcome. some symptoms may linger. PTSD has even been identified in some heart attack patients. and terrorism. However. either first or simultaneous with the GAD. it will likely continue. For days or weeks afterwards. rape. Among other things. He now approached the CBT and progressive relaxation with renewed zest. some of the same anxiety you had after your accident.” Some of the same symptoms develop in survivors of other natural or man-made disasters.

through bad dreams and flashbacks. she tried to avoid the storeroom. she spent most of the time alone in her bedroom. Once she returned to her hometown to live. which is often important in selecting treatment. several times she awakened screaming with a nightmare about being trapped in a sealed box. she paid for the procedure out of her separation pay. many patients also experience depression. Though closely questioned. she would cry. Aretta felt depressed and guilty (“Though in my saner moments. she discovered that she was pregnant. Avoidance. A wrenching experience. I don’t believe I led him on”). finding it in about 40% of military and 15% of civilian . Indeed. he had clenched a knife in his fist. Many PTSD patients feel guilty: “I should have done something to prevent it” may seem irrational. he threatened to kill her if she reported him. during which she felt the same fear and horror as on that day. After a typical delay. The abortion left her feeling empty and “more guilty than I ever thought possible. fearful. Re-experiencing. and she trembled whenever she entered the storeroom. she never even telephoned her former boss.Anxiety and Panic 106 storeroom. Arousal. even using a knife. it powerfully reminded her of the afternoon she was raped. Like Aretta. Returning to live with her parents. she began to relive her experience. she refused to use a knife. A 2007 review of the literature confirms the legitimacy of delayed onset.” because she couldn’t really keep her mind on anything. the military physicians had refused to perform an abortion. sometimes she seemed to be living the rape all over again. Then. She reported that she “just sat. From then on. whenever she was assigned to KP in the mess hall. she would never reveal the name of the sergeant who had raped her. On the rare occasions she helped her mother in the kitchen. Several mornings. and her pregnancy earned her a general discharge under honorable conditions. invariably. afterward. PTSD symptoms vary enormously with the individual. Others may startle easily or maintain an abnormally high degree of vigilance. though it is unclear just how frequent this pattern occurs. some clinicians apparently do not believe that such a pattern even actually exists. She often had flashbacks. even reading. Aretta tried to avoid anything that reminded her of her experience—talking with army friends. and helpless. her heart beat fast and her hands shook. Delayed onset (6 months or longer after the trauma) of PTSD symptoms has been long reported. If she had to enter it. caused Aretta to feel threatened. She wouldn’t talk to a friend who had enlisted with her.” and she couldn’t breathe. who feel guilt and shame at surviving when friends did not. but this attitude affects even combat veterans. but four elements will always be present: • • • • Trauma. Some people develop amnesia for aspects of the traumatic experience. Though she begged them. It usually took her hours to fall asleep.” Although Aretta had been told she could have her civilian job back. which might traumatize anyone. and she wouldn’t watch a TV comedy about the army. Aretta’s severe insomnia and difficulty focusing attention on reading repeatedly demonstrated a state of high arousal. she went on sick-call because of a panicky feeling that her heart would beat “right out of my chest. Throughout the ordeal.

It is increased in those who have less education and when the person senses a loss of family or community support. which is why many schools curtailed videotape showings of the collapse of the World Trade Center after 9/11. The one-year prevalence of PTSD is as high as 8% lifetime. In the case of rape. a history of childhood sexual abuse may increase risk of PTSD symptoms. the other to the person. one tied to the trauma. PTSD patients are likely to have other anxiety and mood disorders. the more direct your exposure to a threat. Many clinicians recommend a form of exposure therapy that forces one . etiology. helplessness. Differential diagnosis Anxiety due to substance use Anxiety due to a medical condition Major depression Somatization disorder Panic disorder Social phobia OCD Adjustment disorder Psychotic disorder Epidemiology. Although not yet well studied. In all. In fact. However. On a personal level. Even hearing about something awful. Exposure to continuous or repeated trauma increases risk. the risk of PTSD increases with the degree of fear. and comorbidity You wouldn’t have to be hurt or even threatened to develop symptoms of PTSD—watching someone else die or sustain injury can provide the traumatic stimulus. Substance misuse is also highly comorbid. and other natural disasters. as will two-thirds of former prisoners of war. Nearly a quarter of those who survive heavy combat will have symptoms. there are hints that genetics could play an important role. Why does trauma cause PTSD symptoms in some people but not in others? There are two sorts of reason. perhaps 5% of men and 10% of women have at some time had PTSD. Of course.Anxiety and Panic 107 cases. There are suggestions that a delay in symptom development may be more likely in those who have suffered severe injuries or continued on deployment in a theater of combat. floods. the prevalence will be much higher in VA mental health clinics. perhaps because of greater sensitivity to stress. Greater injury or threat to life both increase the risk of PTSD. with women at greater risk than men. Treating PTSD PTSD symptoms are a conditioned response—involuntary behaviors learned during the course of the traumatic experience—which suggest that patients can “unlearn” them with psychotherapy or a behavioral technique. can be traumatic. Older adults are less likely than younger adults and children to develop symptoms. VA psychiatrists find major depression to be quite usual among patients whose trauma is combat-related. the more likely you are to develop symptoms. or horror experienced. PTSD symptoms are less likely to follow forest fires. such as a life-threatening illness in someone you know. The presence of a mood disorder or another anxiety disorder also increases the risk of PTSD.

including substance misuse. most patients will come to believe that their symptoms are due not to personal weakness but as a reaction to severe stress. and many others experience relatively mild symptoms. Especially at the onset of treatment. Of course. and who manage either to avoid or discard maladaptive coping devices such as the use of denial and isolation. after her first attempt. A favorable outcome is likely in those who do not experience subsequent episodes of trauma. who have a good social support system. Some studies suggest that the monoamine oxidase inhibitors work especially well for the insomnia and recurring thoughts. Sometimes. about half of PTSD patients recover within a few months. and to report what she could see in her mind’s eye. Symptoms of PTSD that sometimes develop in ICU patients have recently been prevented by getting them out of bed and walking. CBT is probably just about as effective at teaching new ways to respond to something frightening. it should continue for at least 6 months. her therapist encouraged her to practice confronting her fears just this way when she was alone. she felt more comfortable. as if it was occurring at that moment. or symptoms of hyperarousal (poor concentration. However. her anxiety began to recede. Antidepressants are a good first choice because they attack most of the anxiety symptoms as well as the depression that so often accompanies this disorder. It took some persuasion before she’d even try. her mood symptoms and eventually her insomnia improved. Of these. Whichever drug is chosen. and memories. dreams. Patients write down their irrational beliefs and thoughts and figure out more helpful responses. Aretta started on sertraline (Zoloft). the events or thoughts reminiscent of the event. they become able to face the situations that precipitate their symptoms. seeking out and adhering to treatment is an important step in promoting recovery. and only a few seem to become worse and worse. to the extent permitted by their medical complications. Aretta’s therapist asked her to describe the rape. even a small percentage of a huge base still yields a large number (consider just the millions of people who have seen combat in the past 60 years). easy startling). Although any of the other SSRIs would probably have worked. Regardless of whether treatment is with behavior modification or psychotherapy. who don’t have other mental disorders. Once she got to 100 mg/day. With sessions of virtual exposure therapy. Mood stabilizers such as lamotrigine have been effective against PTSD symptoms in civilian and military patients. Course of illness Even without treatment. after a few trials revealed that nothing bad would happen. it will probably be needed for at least a year. Recent studies have shown that the alpha-1 adrenergic blocker prazosin (Minipress) can be helpful for someone who is especially troubled by flashbacks. some have symptoms that wax and wane. she cried for the rest of that session. To speed things along. as in combat or concentration camp experiences. The following day. nightmares.Anxiety and Panic 108 to confront. possibly in real life but more often through imagery. Eventually. most patients need medication. based on a rational interpretation of events devised with the therapist. exposure may be too traumatic. Only about 10% of those who develop PTSD remain ill for many years. Then. .

or horror None required (may be part of reliving) 1+ required 3+ required 2+ required More than 1 month Yes Not required (!) Acute Stress Disorder Same 3+. immediately and in detail. taken just after a severe automobile accident or other trauma. On the brighter side. careful scientific studies have proven not only that that the one-shot debriefing process doesn’t prevent PTSD. Full abbreviated criteria (I know. By providing information about common emotional reactions to trauma and stressing the importance of talking about the incident. Every physician should be prepared for a frank discussion with patients about the health benefits of returning as soon as possible to normal daily life. especially if that someone has deep pockets. Balancing the need for recovery with the desire for compensation can pose a real dilemma. this approach is supposed to avoid the development of symptoms. someone must pay. A series of recent articles from Australia demonstrate that prolonged (imaging followed by in vivo) exposure therapy cut in half (33% versus 77%) the likelihood of longer-term symptoms among survivors of civilian automobile accidents or nonsexual assault. it actually makes some people worse. whenever bad things happen. Such litigation is likely to be hard-fought and prolonged. medical cause Posttraumatic Stress Disorder Actual. in which the incident is reviewed with the victim. What else should we note about such patients? For one. others gradually improve on their own. A particularly horrendous experience can cause acute symptoms. either. but there are steps that can be taken to improve the outcome for people who have been acutely. threat → fear. some evidence suggests that starting CBT soon after the trauma may help prevent the onset of PTSD. recently traumatized. Someone who must demonstrate continuing symptoms to prevail in court risks prolonging the disability. Exposure was more effective . In our litigious society. they are defined similarly to PTSD. Trauma Dissociative symptoms Reliving the event Avoidance Increased arousal Duration Distress or impairment R/o substance. That’s the intent of debriefing. in the table below are the essential differences. Antianxiety drugs. The editorial box makes it clear that debriefing isn’t especially effective. However. it’s an oxymoron) are given in Table 7b at the end of the chapter. during/after trauma 1+ required 1+ required 1+ required 2–28 days Yes Yes The most important factor that determines how a person will react to trauma is the nature. Another caution concerns the issue of compensation. That’s where the relatively new diagnosis of acute stress disorder comes in. even in someone with no risk factors for a stress disorder (page 107).Anxiety and Panic 109 Editorial: Speaking of Avoidance… A terrific approach to any traumatic event would be to prevent PTSD from developing in the first place. and the outcome may depend on the apparent degree of damage. helplessness. Acute Stress Disorder Anyone who’s been paying really close attention will have noticed a hole in the PTSD criteria: They say nothing about people whose trauma occurred within the previous month. don’t seem to prevent PTSD. especially the degree of that trauma. using deep probes to elicit the emotions and thoughts experienced. Some ASD patients go on to develop PTSD.

moved out to live with her boyfriend. For the last several months her mother had helped her. clinical obsessions are unwanted mental events that shove their way into consciousness.” Judy explained. even though she had just showered. we may describe someone’s behavior as being “compulsive. On one point they agreed: Paulette’s problem was tearing the family apart. Judy and Peter Digby went for marriage counseling (“divorce counseling.” Then. she wore only one (“I might get up and touch something”). and Peter stopped cooperating with his wife’s need to “protect” their daughter by joining the extreme behavior. Judy confronted her about her 10 visits to the bathroom that day. Whenever her mother asked what she was doing. working her way through the cupboards. compulsions are mental acts or repetitive behavior that someone feels the powerful urge to perform.” but once she forgot to lock the door. she wore three pairs of gloves. which the whole family had to wear indoors. At 6month follow-up. I just can’t help it. two events coincided: her sister Candy. interrupting the normal course of thought. In contrast.Anxiety and Panic than cognitive restructuring. (“She seemed so frantic. and I always feel so yucky.”) From her volunteer job at the hospital. Paulette cleaned the kitchen. Otherwise. “I had to do something.” Peter called it) because they fought constantly about their 17-year-old daughter. we’re talking about simple exaggerations of normal thinking and behavior—what we mean is that the person pursues an idea excessively or insists that something be done a particular way.” .” he grumbled. That evening. Every couple of days. Paulette cried. Now she washed half an hour at a time. and finishing up under the sink. She also spent a lot of time in the bathroom. It started a year earlier when one of her jobs was taking out the garbage. She even had special gloves for washing the other gloves. She wore gloves to do this because she had seen a TV show about bacteria.” That was several months earlier. she’d say “nothing. Judy only redoubled her efforts. usually to decrease the anxiety caused by an obsession. “It’s stupid and I hate it. When she slept. which still produced enough improvement that it should be considered for those who are unable to withstand the rigors of prolonged confrontation. “She’s dragged the whole family down. starting with the sink and stove. at least a dozen times a day. Judy peeked in and saw her scrubbing her hands. patients maintained their improvements. Paulette had also taped all the doorknobs so that none of the latches in the house worked—she could push or pull the doors open with her wrist. fed up with the home climate. At about that time. which made him even angrier at his daughter. scouring the already sparkling floor on her hands and knees. 110 Obsessive–Compulsive Disorder We sometimes speak casually of being “obsessed” with a thought or idea. “She makes a production out of what normal people take for granted. I just can’t stop thinking about germs. Judy had brought home scrub booties. Putting on rubber gloves whenever she grasped the lid gradually developed into a complicated routine for removing the gloves without touching the outsides of them with her fingers.

divided her parents. such as locks. others count or check things. Joseph could only get into bed at night by following an agonizing procedure—step in and out of his slippers three times (later. and feel embarrassed. three times three. the problem may seem innocuous. The obsessional ideas can generate enormous anxiety. Paulette’s fixation on cleanliness is a common obsession. whereas attempts to resist compulsions can lead to tension that is ultimately relieved only by giving in to them. or gas and electric appliances. Differential diagnosis Anxiety due to substance use Anxiety due to a medical condition Major depression Somatoform disorders (Hypochondriasis. Other obsessions involve thoughts (distressing ideas about sex and numbers that are believed to be unlucky). Paulette responded to her obsessions by cleaning compulsively. and she couldn’t resist performing the rituals that momentarily reduced her anxiety about germs. These mental events are often violent.” in which it takes hours to complete a simple household chore. then tops. the more the person performs compulsive rituals. turn it down to a 45-degree angle three times. sexual. mental acrobatics (for example. They usually recognize how peculiar their obsessive thoughts and compulsive rituals must seem. sacrilegious. and relatives like Paulette’s mother may try to ease the person’s fears by assisting with the rituals. and impulses (feeling compelled to scream during religious services). smooth out his bedspread. The obsessions and compulsions that absorbed her life. just compulsions that they must perform according to set rules. then three times three times three). That’s partly why OCD was once thought to be rare—shame and the fear that they are going crazy make people hide their guilty secrets even from best friends and physicians. However. pictures or images of dreaded actions (such as disrobing in public). remove them. Paulette’s condition developed so gradually that it took months for her family to seek professional help. A few people have “obsessional slowness. and drove away her sister constitute obsessivecompulsive disorder (OCD). the worse the OCD becomes. A very few have obsessions without compulsions. fears (perhaps of diseases like AIDS or hepatitis). he had to start all over again. or senseless. and repeat three times. If he was interrupted or began to doubt whether he had followed all the prescribed steps. Body dysmorphic disorder) Substance misuse GAD Panic disorder Social or specific phobia . OCD sufferers often devote much time to what most of us might view as the infrastructure of our lives. Others have mental compulsions (such as ritualized praying) that are not externally apparent. At its onset. put his pajamas on bottoms first. visually dividing a line exactly in two). disgusting.Anxiety and Panic 111 Symptoms and diagnosis of OCD Paulette couldn’t control her thoughts about contamination. Still others have no obsessions at all.

12–16 weeks). but hardly any body part is immune—ankles. and for patients who need even more assistance. in which case both diagnoses would be made. If they do go out. People with BDD may spend much of the day brooding over their imagined deformities.Anxiety and Panic Impulse control disorders (hair-pulling. and over 80% have trouble on the job or at school. will help around two-thirds of patients with BDD. they may pick or scrape away at their skin until real pitting and scarring develop. or perhaps the slightest hint of a flaw. it appears so far that drugs like fluvoxamine (Luvox). It encourages patients to stop clinging to the behaviors they have used to escape from their fears. may work well. nearly a third become housebound. but Tamara was unconvinced. a few succeed. given in high enough doses and for long enough (typically. Some clinicians find that buspirone (60-90 mg/day) augments the antidepressant effect. The TCA clomipramine (Anafranil) can also help. arms. may be affected. Note the differences between OCD and OCPD: patients with the former have actual obsessions and/or compulsions. A given patient could have both conditions. they are obliged and. The first two hadn’t thought they could improve on nature’s gifts. she had lately begun wearing her long hair draped across half her face. to conceal their features with clothing or bandages. Patients with the latter are concerned with issues of control. Almost all have impaired social lives. cautiously administered. “I’m ugly and misshapen. Tamara would be persuaded to throw away her cover-ups and discard her magnifying mirrors. These men and women (who are about equally represented) are haunted by their appearance. In the effort to repair their fancied deficits. Exposure and response prevention (ERP) can help reduce the anxiety and unwanted behaviors. a condition first described over 100 years ago. many patients with BDD request surgery. pathological gambling) Psychotic disorders Adjustment disorder Everyday superstitions and checking behavior Obsessive-compulsive personality disorder* 112 Sidebar: Obsessed with Imperfection Stunning and statuesque. Even mental health professionals often don’t know a lot about it. She had lost several boyfriends over her preoccupation with her nose.” she insisted as she scrutinized herself in her hand mirror. usually. Too often. they perceive only disaster. No one knows what causes BDD. hair. Most check mirrors compulsively and compare themselves mentally to those they meet. Tamara had body dysmorphic disorder (BDD). Theirs is an obsession with the impression of imperfection. * . Although repeated double-blind studies have not yet been done. though as many as 1 or 2% of adults. even the pubic bone of one teenager. and even some children. at age 23 Tamara was consulting her third plastic surgeon about her nose. and nearly one-fourth have made a suicide attempt. Most have had major depression. though it probably involves a problem with serotonin neurotransmission. Most often. Where others see beauty. like Tamara. or nose. they worry about the appearance of skin. orderliness and perfectionism. Low-wattage light bulbs in the bathroom may help shift focus from their appearance. they are dissatisfied with the outcome. the combination of fluvoxamine plus clomipramine. Half are hospitalized at some time. To smooth away the tiny bumps and blemishes only they can see. Even those who think they have been improved may just shift critical attention to another body part. they may try.

these abnormalities resolve with effective treatment. For example. patients with severe BDD will probably also need long-term “thought repair” through CBT: identifying automatic and unrealistic thoughts and core beliefs. it usually begins in the teens or early 20s.” a group that also includes Tourette’s disorder. eating disorders. BDD falls into what some call the “OCD spectrum of disorders. each of which features obsessional thinking and ritualized behaviors. OCD has strong biological roots. Patients with complicated. though. The response prevention part: she was allowed to wash her hands only four times a day. OCPD. GAD). though it can affect children of 10 or even younger. Positron emission tomography has found abnormal metabolism at sites deep within the brains of people who are having obsessions. several studies have found that OCD in a relative increases a person’s risk for the disease fivefold. and replacing them with more useful thinking. or moderate to severe OCD should probably use both. drugs and psychotherapy. Each of these disorders is included in a DSM-IV section different from OCD and the other anxiety disorders. can effectively address OCD. In both sexes. OCD patients are likely to have other anxiety disorders (phobias. and kleptomania. At 200 mg/day. A complex illness that continues to perplex patients and professionals alike. Treating OCD Two basic approaches. In recent years. In an effort to jump-start the recovery effort and ensure success. Whatever the initial starting point. she reluctantly surrendered her gloves and spent an hour each day rubbing her hands in a bucket of dirt (exposure). childhood OCD has developed apparently as an immune reaction to streptococcal infections. it remains to be demonstrated to what extent they might be related.” she later admitted. high doses (and sometimes. I lightened up. It is somewhat more frequent among women than men. and comorbidity We now know that OCD is actually fairly common. biologists have uncovered considerable evidence implicating the neurotransmitter serotonin.Anxiety and Panic 113 However. Epidemiology. the uncontrollable and disconcerting tendency to have motor tics and blurt out obscenities. SSRI drugs such as fluvoxamine and the TCA clomipramine are effective in treating OCD. and tics and Tourette’s disorder. Paulette’s physician began with the SSRI fluvoxamine at 50 mg/day and increased it by 50 mg every 4 or 5 days. anorexia and bulimia nervosa. they may have major depression. “Mom had to sit with me for the first hour or so each day. Tamara learned to tell herself that her thoughts about her nose were just part of her BDD. she felt less stressed and was referred to a therapist for treatment with (ERP). Fluvoxamine has been specifically approved by the FDA for OCD. panic. etiology. a long duration of treatment) are needed for the SSRIs to be effective. “The anxiety was really terrible at first. There is also a familial link to Tourette’s disorder. After a few days. Paulette was told that she would improve faster if she intentionally “contaminated” herself by touching germ-laden objects. longstanding. Although the genetics aren’t thoroughly worked out. though boys tend to outnumber girls (it begins earlier in boys). challenging them. no surprise. at some time affecting about one in 50 people. though other . In addition.” Typically.

there is still plenty of opportunity to miss readily correctible etiologies of nonspecific anxiety symptoms. However. starting at 25 mg/day and increasing to an average of 200–250/day. If she had had only obsessions. if they also have a personality disorder. though repetitive behaviors occur in Tourette’s disorder and in temporal lobe epilepsy. for the unwary. but that doesn’t mean we can relax our vigil for medical causes of anxiety. CBT would have been an alternative. Include families in the overall treatment plan. For example. ERP works best for patients who are highly motivated and have both obsessions and compulsions. Some patients need augmentation of an SSRI with clomipramine or with a low-dose atypical antipsychotic agent such as olanzapine or risperidone. if they have washing rituals. even for those who continue to have some symptoms. It is also vital that those who live with an OCD patient learn to stop accommodating the compulsions. visualizes the therapist banging a fist on the table and shouting “Stop!”). intervention. Anxiety Due to Physical Illnesses or Substance Use You won’t find physical illnesses and substance use as causes of most of the named disorders we’ve covered in this chapter.Anxiety and Panic 114 SSRIs have also proven effective. this lack of evidence parallels most clinicians’ abandonment. Currently. . Paulette’s family had to stop using gloves and decontaminating the house—these behaviors reduced Paulette’s anxieties short-term but ultimately worsened the problem. thermal capsulotomy is the procedure of choice. she could have been offered the thought stopping method (where the patient. of “inner conflicts” as a cause of OCD. The tricyclic antidepressant clomipramine. in recent years. Relatives need education so that they can stop casting blame (on themselves and the patient) for behavior neither can control. However. with vigorous treatment the overall outlook is far brighter than it was even a couple of decades ago. In the Table 8 listing of a variety of mental symptoms associated with 60 medical disorders. is effective but is beset with side effects and has a slow response time. Trials of different drugs may be needed to find the one that works best. neurosurgery remains a possibility for those rare patients who are incapacitated by OCD and who respond to nothing else. they don’t spell out the criteria necessary to diagnose OCD. Course of illness Severe OCD is hard to treat. Although it only rarely comes to this. About a third of patients who have such surgery function better. OCD patients generally have more trouble achieving a satisfactory response if they’ve been hospitalized or more or less continuously ill. you’ll find that many of them include anxiety. There is no evidence that dynamic psychotherapy is of much use. those with more severe symptoms and their families should brace themselves for a long campaign. Had Paulette been unable to tolerate the anxiety ERP sometimes generates. though perhaps less effective. upon experiencing obsessional thinking. Although medication or psychotherapy alone may help those with milder symptoms.

A few moments later. also 96. even once as he and his wife were making love. then narrows. gasping for breath and clutching his chest. Isaac’s attacks rapidly swell to a terrifying climax. and 101 6. his family doctor pronounced him physically sound. Nearly every time it happens he thinks. It was during an algebra test that his heart started pounding so hard he couldn’t concentrate on the paper in front of him. Suppose Isaac’s symptoms had begun after his involvement in a fatal automobile crash. He may go for several months without much trouble at all. What circumstance(s) would permit you to diagnose GAD? [p 103] . while driving to visit his mother. and what are the other two classes of phobia we currently diagnose? [p 92. “I’m about to draw my last breath. and 107] 5.Anxiety and Panic 115 Review Isaac had his first attack when he was 16. What symptoms of panic attack did Isaac have? Which did he lack? [p 91] 2. What diagnoses would you put at the absolute top of your differential diagnosis for Isaac? [p 114] 7. until he loses his peripheral vision. what evidence would allow you to decide whether he also suffered from OCD? [p 117] 8. His heart pumps so fast that he can’t even count the beats and he feels like all the breath has been sucked out of him. He asked to be excused and stumbled out of the classroom. How do the treatments recommended for these three classes of phobia differ? [p 94. The next day. What named phobia does Isaac suffer from. he’s had episodic attacks of feeling acutely frightened and disoriented. Sometimes a pain begins on the left side of his chest and surges like a tidal wave. [ p 92] 3. Outline the steps you would recommend for treatment of Isaac’s symptoms. 98. Isaac worries about his panic attacks. then experience attacks daily for weeks on end. Beginning abruptly and without warning. 1. the teacher found him sitting on the bathroom floor. Of course. What three sets of symptoms would you especially be looking for to rule in/out PTSD? [p 106] 4. on his job as a city planner. but in the 20 years since.” He can sometimes abort his attacks by breathing into a small paper bag. but he feels desperate to find something that will get rid of them permanently. At first his vision blurs. spilling into his abdomen and pelvis. Isaac’s attacks have occurred in a variety of circumstances—at the theater. Suppose Isaac had obsessive thoughts concerning recurring panic attacks.

4 or more of: Chest pain or other chest discomfort. (3) No other mental disorder better explains the symptoms. doing something to avoid or combat attacks 116 Exclusions/Other Not caused by substance use. (2) The patient a) Avoids these situations/places. or faint. consequences Material change in behavior (eg. or interferes with patient’s usual routines or personal. GMC Meets criteria for agoraphobia† Social phobia: A strong. GMC Not better explained by another anxiety or mental disorder Specify type: Situational (eg. unexpected panic attacks* and Agoraphobia† Panic disorder. Tremor †Criteria for agoraphobia: (1) One or both of a) Anxiety about being where escape is difficult or embarrassing. other abdominal discomfort.Substance Misuse Table 7a. help might not be available. or c) Requires a companion. Anxiety disorder due to general medical condition More than half the days for 6+ months. heights. b) if attack occurs. unexpected panic attacks* Agoraphobia w/o history of panic disorder Specific phobia: A strong. compulsions History. keyed up Tiring easily Trouble concentrating Irritability Increased muscle tension Trouble sleeping Prominent anxiety. 1+ of: Concern about more attacks Worry about meaning of attacks. Simplified Criteria for DSM-IV Anxiety Disorders Disorder Symptoms Panic disorder w/ Agoraphobia: Recurrent. must have symptoms 6 months or more Marked distress. skips beats. History/physical exam/laboratory evidence either: personal functioning Substance-related anxiety Symptoms developed within 1 month of intoxication No other mental disorder better explains disorder or withdrawal. Fear of dying. or b) Endures them. panic. panic. social. obsessions. excessive anxiety and worry about several events or activities 3+ of: Feeling restless. physical exam or laboratory evidence suggest a GMC has caused symptoms. or symptoms Medication use caused symptoms Not solely during delirium *Criteria for panic attack: sudden onset of episode that peaks within 10 minutes. Dizzy. work functioning Generalized anxiety disorder Clinical distress or impaired work. Fears loss of control or insanity. persistent. Nausea. thunderstorms) Blood–injection–injury Animal Other Not better explained by another anxiety or mental disorder Not caused by substance use. races. Numbness or tingling. Choking sensation. fear that is excessive or unreasonable is set off by an object or situation that is present or anticipated For a month or longer. Never has met panic disorder criteria Not caused by substance use. GMC Does not have agoraphobia Not caused by substance use. air travel) Natural environment (eg. Chills or hot flashes. GMC Specify whether Generalized (patient fears most social situations) Not caused by substance use. Sweating. edgy. repeated fear of showing anxiety sx or embarrassment while watched by others Phobic stimulus almost always causes anxiety (may be panic attack) Patient realizes fear is unreasonable or excessive Patient avoids stimulus or endures w/ severe distress Under 18. social. social. Derealization. w/o Agoraphobia: Recurrent. personal functioning No other mental disorder better explains symptoms Not solely during delirium Prominent anxiety. Heart pounds. compulsions Clinical distress or impaired work. lightheaded. Shortness of breath or smothering sensation. GMC Another Axis I disorder doesn’t provide the focus of the anxiety and worry Doesn’t occur only during mood. but with distress. obsessions. psychotic disorder or PTSD or pervasive developmental disorder .

or interferes with patient’s usual routines or personal. thoughts. (2) Tries to avoid activities. or emotionally unresponsive. work functioning Acute Stress Traumatic event experienced or witnessed by patient (1) involves actual or Symptoms begin within 4 Disorder threatened death or serious physical injury to patient or others and (2) patient wks of trauma feels intense fear. social. (3) Poor concentration. or helplessness Patient repeatedly relives event in 1+ of: (1) Intrusive. horror.. All are required: (1) Recurring. (3) Behaviors aim to reduce distress or prevent something that is dreaded. (4) Behaviors are either not realistically related to the events they are supposed to counteract. (2) Angry outbursts or irritability. (3) Amnesia for an important feature of the trauma. (5) Physiological reactions to these cues (e. (2) Behaviors occur in response to an obsession or in accordance with strictly applied rules. such as getting legal or medical help or tell others about the experience ‡Criteria for obsessions. or are excessive for that purpose.Substance Misuse Table 7b. irritability. take up time (>1 hr/day). (5) Not just a worsening of Amnesia for important aspects of the event another disorder Patient repeatedly relives event in 1+ of: (1) Recollections (dreams. flashbacks. (4) Excess vigilance. Not a brief psychotic images. people. thoughts). tachycardia. work functioning.** or both. (3) Mental distress as disorder reaction to reminders of the trauma Patient strongly avoids activities. At some time during illness. (2) Repeated. or interfere with usual routine or personal. counting. Simplified Criteria for DSM-IV Anxiety Disorders (cont. conversations. eg excessive vigilance. .g. or neutralize them. content of obsessions/compulsions not limited to it Not caused by substance use. and (4) is aware they are the product of the patient’s own mind. (4) Marked mental distress reacting to cues that symbolize some part of the trauma. social. (3) Feels as though events are reoccurring (e. people places. (2) decreased awareness GMC of surroundings. thoughts that are reminders of the trauma Marked symptoms of anxiety or hyperarousal. conversations. (4) Depersonalization. handwashing).g. GMC Symptoms last > month Score as: Acute (symptoms last <3 months) Chronic (symptoms last more than 3 months) With delayed onset (symptoms begin 6+ months after the stressor) Posttraumatic stress disorder Traumatic event experienced or witnessed by patient (1) involves actual or threatened death or serious physical injury to patient or others and (2) patient feels intense fear. numb. (5) Feels detached or isolated from others. (4) Has markedly decreased interest or participation in important activities. Symptoms cause 1+ of: severe distress.) Disorder Symptoms Obsessivecompulsive disorder Obsessions. suppress. horror. places that recall the trauma. as in a daze. Feels detached. (2) Interfere with patient’s usual routines or personal. patient recognizes that these are unreasonable or excessive. poor concentration. social. (2) These are not just extreme worries about ordinary problems. feelings. (6) Restricted ability to love or feel other strong emotions. (2) Sense of reliving the event. or helplessness Duration is 2–29 days During or just after the event. distressing recollections. flashbacks). persistent thoughts. increased BP) Patient repeatedly avoids stimuli and has numbing. increased startle response 1+ of: (1) Symptoms cause patient marked distress.g.. All are required: (1) The need to repeat physical or mental behaviors (e. **Criteria for compulsions. distressing dreams. (3) Block patient from doing something important. work functioning 117 Exclusions/Other If patient has another Axis I disorder. or images inappropriately intrude into awareness and cause marked distress or anxiety. (7) Feels life will be brief or unfulfilled 2+ of these new hyperarousal symptoms: (1) Insomnia. shown by 3+ of: (1) Tries to avoid feelings.. (3) Patient tries to disregard.‡ compulsions. patient has 3+ symptoms of dissociation: (1) Not caused by substance use. (3) Derealization. (5) increased startle response Marked distress. restlessness. insomnia. impulses.

Substance Misuse Table 8. Mental/emotional symptoms associated with selected physical illnesses
Emotional/behavioral Symptoms Hallucination s Delusions Suicide Ideas Labile mood Obses/comp Withdrawal ↓ Judgment Depression Catatonia Cognitive symptoms Disorientation ↓ Memory Slow Thought Inattention Dementia Delirium

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Anxiety

Mania

Adrenal insufficiency AIDS Altitude sickness Amyotrophic lateral sclerosis Antidiuretic excess Brain abscess Brain tumor Cancer Cardiac arrhythmia Cerebrovascular disease Chronic obstructive lung disease Congestive heart failure Cryptococcosis Cushing’s Deafness Diabetes mellitus Epilepsy Fibromyalgia Head trauma Herpes encephalitis Homocystinuria Huntington’s Hyperparathyroidism Hypertension Hyperthyroidism Hypoparathyroidism Hypothyroidism Kidney failure Klinefelter’s Liver failure Lyme disease Meniere’s Menopause Migraine Mitral valve prolapse Multiple sclerosis Myasthenia gravis Neurocutaneous diseases Normal pressure hydrocephalus Parkinson’s Pellagra Pernicious anemia Pheochromocytoma Pneumonia Porphyria Postoperative states Premenstrual syndrome Prion disease Progressive supranuclear palsy Protein energy malnutrition Pulmonary thromboembolism Rheumatoid arthritis Sickle cell disease Sleep apnea Syphilis Systemic infection Systemic lupus erythematosus Thiamine deficiency Wilson's

x x x

x

x x x

x x x

x x x x

x x x x

x x

PTSD

Panic

x x x

x x x x

x x x x

x x

x

x

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x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x

x x x x x x x x x x x x x x x x x x x x x x x x x

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x x x x x x x x

x

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x

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x x

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x x

x x x x

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x

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x

x x x

Adapted from Morrison J: Diagnosis Made Easier. New York, Guilford, 2007.

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Further Learning
I don’t have nearly enough recommendations for works that will guide you “inside” the mind of people who have anxiety disorders. I’d appreciate hearing from anyone who has run across such material. For GAD, there is Fear Strikes Out, the story of Jim Pearsal, who played baseball for the Boston Red Sox back in the mid-Twentieth Century. Please email me with any thoughts you may have about other works that are especially good at portraying people with anxiety disorders. Ruth Rendell: in Live Flesh, her main character Victor has a morbid fear of turtles (chelonaphobia), so severe that he cannot bear even to hear the word pronounced. “Panic came over him like a kind of electric suit…” Victor has and aunt with agoraphobia, and author mentions a kind of systematic desensitization in passing. The British mystery writer Ruth Rendell (and her nom de plume *) have turned out dozens of titles in the past 40 years. A number of them feature characters with rather well-drawn mental disorders, especially anxiety disorders. Here is are a few of them: Victor in Live Flesh is an almost inadvertent killer who has a morbid fear of turtles. A minor character in The Bridesmaid is Cheryl, sister of the protagonist, who suffers from well-described pathological gambling [chapter 19]. She has completely lost control of her gambling, doesn’t see it as a problem (an interest or hobby), borrows and steals to support her addiction. Demon in My View features Arthur, a psychopath who strangles women. In Grasshopper, the heroine, Clodagh Brown, has incapacitating claustrophobia, yet she enjoys climbing on roofs of building. Winston in 1984: a fear of white rats [check this out].

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CHAPTER X

Substance Misuse
11,346 Despite huge investments of resources into understanding causes and devising effective treatments, our society continues to struggle with substance abuse. Headlines in early 2001 cited substance abuse as the number-one health problem in the United States. Although some people still consider abusers of alcohol and other substances to suffer from nothing more that moral laxity, careful study has proven substance misuse* to be no different from any other medical disease. Like many other conditions, substance abuse disorders run in families, have distinct symptoms, psychopathology, and courses, respond predictably to certain treatments and, if not treated, have well-defined, predictable outcomes. These characteristics have led experts to refer to substance dependence as a chronic illness that should be regarded like any other chronic medical disease as regards insurance, evaluation, and treatment. Some people in the early stages of substance misuse stop instantaneously, or with a nudge. If they keep using and don’t seek help, many medical complications and emotional and behavioral sequels are possible: disorders of mood, anxiety, sleep, and sex, as well as psychosis, dementia, and delirium. Clinicians without much specialized mental health training often provide services for patients with substance use problems, so it is imperative that general physicians have a strong working knowledge of how different drugs affect emotions, cognition, and behavior, and cover many aspects of treatment, both in general and for specific addictions. The language we use to describe and define substance use disorders rest on four pillars: intoxication and withdrawal, abuse and dependence. We’ll use the slightly artificial device of the composite Monaghan family to illustrate these concepts. Del Monaghan, a 45-year-old salesman, had tried marijuana a few times in college. Early one Sunday morning, intoxicated on vodka, he had to stop every block or so just to bring the street ahead into focus sufficient to continue the drive home. The following day, as his headache subsided, guilt and fear made him resolve never again to put himself in that position. Even today, when he attends a ball game he’ll drink a beer or two, but never three, and he has exactly two cups of coffee each morning. Del worries about his daughter Eva, 21. In her final college year, Eva got two tickets for driving while intoxicated and had several times been too hung-over to attend class. She and her mother spent Christmas vacation fighting about her drinking, but she refused to seek treatment. She even stayed sober for 2 weeks, just to prove that she didn’t “have to have it.” Remembering his own youthful misadventures, Del couldn’t bring himself to confront Eva about her behavior.
*

As we’ll see later, the term “abuse” has a special and specific diagnostic meaning. It is to avoid confusion that, throughout this book, I’ve used the term “substance misuse” for the generic concept of “someone who uses too much of a substance and therefore has problems.” Many writers plow right ahead with “substance abuse,” so what if it’s confusing? I’ve opted for clarity.

a patient must experience three of the following seven DSM physiological. the patient reduces or abandons important work. Stanley was proud and wealthy. Months later. he had put his head on Del’s shoulder and cried. • • • • • Stanley easily qualifies as a dependent drinker. Once we spoke of “addiction. The patient spends much time obtaining. The amount or duration of use is frequently more than intended. Withdrawal. a self-made man who never finished high school but had used his experience as a produce buyer to become a grocery importer. (Although DSM-IV lists several caffeine-related disorders. Either of : a) the patient experiences withdrawal effects typical for the substance or. By the time he was 40. b) uses the substance—or a related one—to mitigate or avoid withdrawal symptoms. 121 DEPENDENCE AND ABUSE Eventually. Stanley.Substance Misuse Del’s concern is fed by memories of his own father. finances. Just using a drug. b) continued use of the same amount yields less effect. The shakiness he experienced . we all overuse something. • • Tolerance. Within a few years. all to no avail. indeed. using. and 7 million had used one or more within the last 30 days. Dependence is what we now call heavy. or leisure activities. from casual and social use. doesn’t spell a diagnosable substance use disorder. To qualify for dependence of any substance.” a term many experts now reject because it is imprecise—we use it for people who like to eat chocolates or read mysteries. family or friends. Threatened with divorce. even if it’s only caffeine. maladaptive reliance on any substance. For that to happen. no one proposes limiting traffic in coffee. When he entered a hospital for “the cure. I’m nothing without a drink!” The following winter. in 1999 about 40 million Americans age 12 or over reported using an illicit drug at least once. “I’m a hopeless alcoholic. and behavioral criteria within a 12-month period. he had neglected his business and was drinking his way through the family savings. and the law. It is the critical concept for differentiating heavy and severe substance misuse from other forms of abuse and. the usage must create significant problems such as with health. despite the knowledge that it has probably caused ongoing physical or psychological problems. His huge intake of alcohol (a quart a day) strongly suggests tolerance to the intoxicating effects of alcohol. even an illegal one.) According to the National Household Survey on Drug Abuse. Either of: a) the patient markedly increases intake to gain the same effect or. Because of substance use. Stanley consulted physicians and joined AA. and often drank a fifth of bourbon in a day without so much as slurring his words. cognitive. The patient continues to use the substance. or recovering from the effects of the substance. he was found frozen to death in an alleyway behind the liquor store. social. The patient repeatedly tries without success to control or reduce the substance use.” the sudden cessation of drinking precipitated such severe shakiness and nausea that he checked out immediately and returned to the bottle.

. Rather. he might well have experienced other withdrawal effects such as delirium tremens). the criteria for substance abuse involve legal and social issues: Abuse causes clinically important distress or impairment as shown in a 12-month period by at least one of the following: • Repeated use cause the patient to fail to carry out major obligations at work. However. and he continued to drink despite knowing that it was having deleterious effects on his health. look normal. Whereas these latter patients do have problems resulting from their excessive suse. Stanley Monaghan truly ranks among the most severely affected. you don’t have to have physiological symptoms to be dependent.1). and in most other ways are responsible citizens. The exact same criteria are used to define dependence for any of 10 possible substances (see Table 1). the severity of cocaine or alcohol dependence can be all over the map. or home. have families who care about them. the more problems a person has from substance use. The criteria for dependence. so we say she is polysubstance dependent. therefore. Drinking large amounts of alcohol without appearing drunk indicated that Stanley had tolerance: he needed increasing doses to produce the same intoxicating effect. they aren’t as sick. The severity of dependence varies with the individual. (confusingly) called substance abuse. Physiological dependence is especially typical of alcohol and heroin use. including Stanley’s shakiness and nausea. and group therapy—twice—to try to kick her cigarette habit. the more severe the dependence. People dependent on heroin tend to have most of these symptoms. Polysubstance dependence Oh yeah. a nicotine patch. but in aggregate. school. and the substance itself. spent much of his time drinking. they lack the loss of control that defines physiological dependence—in short. she has 3. and those dependent on marijuana tend to have fewer. Marcia doesn’t have enough criteria to say that she is dependent on any one substance. keeps using cocaine on the weekends despite her doctor’s warning that it’s causing her severe mood swings. For example: During the past year Marcia’s only symptoms of dependence are these: she often drinks more alcohol than she intends. The vast majority of these people are neither criminals nor homeless derelicts. Note that Stanley was physiologically dependent—he had experienced both tolerance and withdrawal (only one is needed to qualify).Substance Misuse 122 when in the hospital is typical of withdrawal (had he remained off alcohol a few days longer. the length of use. Substance abuse The foregoing definitions set off substance dependence from another form of misuse. it means that the person uses at least 3 substances but doesn’t qualify for dependence on any one of them but if the criteria you amass for all 3 are put together. it would equal dependence. Each substance has its own characteristic withdrawal symptoms (Table 25. and she has tried Nicorette gum. Technically. They have jobs. In general. rely on issues of physiological change and loss of control. The formal (DSM-IV) definition of polysubstance dependence is something more than just the use of more than one substance. Of all the patients I have known. Though he tried repeatedly to quit. there is one other issue you could encounter in the welter of our nomenclature. he neglected his work and his family.

augment sociability. Later on. there are still other patients who have been problematic users without qualifying for either substance dependence or abuse—so-called diagnostic orphans— who fall between. and stimulants may provide relief from boredom. or among. fatigue. one of my professors liked to say that the cause of alcoholism was alcohol. The attractions for various substances are given in Table 1. we’d be awash in chemically dependent people. and reduce sexual inhibitions. nicotine. alcohol can brighten a gloomy mood. But if the mere presence of a substance could produce a substance abuse problem. Also. There are repeated legal problems from the substance use. problems in school. By the above criteria. and many dependent patients don’t also have abuse criteria. Further. even knowing that it has caused or worsened social or interpersonal problems.Substance Misuse • • • 123 The patient repeatedly uses the substance even when it is physically dangerous to do so (such as driving or operating heavy machinery). there is no such thing as “polysubstance abuse. especially for the young and impressionable. readily obtainable resource for reduced inhibitions and giddiness. Furthermore.” Although you wouldn’t consider Eva alcohol dependent (she quit for 2 weeks and she lacked other symptoms that suggest loss of control or physiological changes). diagnostic stools. But even these factors together cannot explain why some people become heavy users while others. what’s the attraction? One big factor. of course. biological relatives more likely than adoptive to have alcoholism. All of this suggests that the present nomenclature may not survive the move to DSM-V. Eva is an abusive drinker. most do not. factor analysis reveals equivocal support for validity of alcohol abuse. Opioids. Inhalants offer a cheap. But just what does it mean to label someone a substance abuser? To be valid. is the siren song of peer influence—glamour and social acceptance are especially powerful promoters of common substances such as alcohol. contrary to expectations. give it up or continue to use moderately. sedatives. not clustered tightly together. and she’d had a couple of citations for driving while intoxicated. Stay tuned. If the patient has ever fulfilled criteria for dependence on that substance. Besides the approval of peers. and marijuana. abuse cannot be diagnosed for that substance (though it could be diagnosed for another substance). you cannot become alcoholic. whereas the hallucinogens promise interesting hallucinations and a refuge from reality. We might start by asking. and around 25% of male first-degree relatives of . these criteria sets don’t appear to be hierarchical: criteria for abuse tend to be sprinkled among dependent patients. a number of issues in people’s lives correlate with drug use: a dysfunctional family. drinking had led to fights at home and missed classes. cultural notions of tradition. the diagnoses we use must enable us to make predictions. after a trial or two. whereas support for dependence is robust. Many studies combine to suggest a genetic linkage. the mere prevention of withdrawal symptoms may prove attractive enough to ensure continuing use. It’s true. or pain. to a point: if you never take a drink. For example. The patient continues to use the substance. now scheduled for 2012. a tendency toward impulsive behavior. even religious sanctions (or proscriptions). Whereas there is evidence that some abusers progress to become dependent. Etiology and development of substance misuse In an earlier millennium.

it is often hard to know which is which. though not necessarily as striking. a powerful reinforcer of further substance use. The reason we should care: Whether the substance use comes first or second has important consequences for treatment. physiology (for those oriental people who are intolerant of alcohol). all of the above factors are probably important in causing substance misuse. The use of substances can be primary (driving the mental disorder) or secondary. For example. then reassess the need for . substance misuse develops subsequent to. thus reinforcing the use of these substances. further enhancing the predilection for substance misuse. but it would be a reasonable assumption that his depression began long after his heavy drinking was well established. we probably wouldn’t have gone straight to the use of antidepressant medications. many patients with Axis I or II disorders also have a comorbid substance use disorder. though other studies suggest that in many cases. (On the other hand. In fact. the ADH2*2 allele. The vignette doesn’t give nearly enough details. Substance-related illnesses This short but important section alerts us to the fact that many substance using patients also have other mental disorders. may help protect against the development of alcoholism. some of these. these other disorders may be mood or anxiety disorders induced by the substance use. For example. In fact. The nucleus accumbens is the site of increased release of dopamine in response to the presence of alcohol. heroin. about half of those seeking treatment for a substance use disorder have another mental disorder. Most substances of misuse cause an increased in the release of dopamine in the nucleus accumbens and other ventral brain locations. which might have the unhappy effect of adding the effects of a prescribed chemical on top of ethanol. And. Whatever the initial attraction. and possibly because of. may be trying to treat their own symptoms by using substances. health. A dopamine release reward system may help explain how drug dependence develops and is maintained. for example. Some data suggest that in many instances. On the other side of the coin. For mood and anxiety disorders the associations are positive.Substance Misuse 124 alcoholics are also alcohol dependent. Some shy people find that drugs and alcohol help them make friends. Learning theorists hold that we develop new behaviors by copying what others do. which runs as high as 90%). amphetamines. 40-50% are so affected (exclusive of nicotine. His depression might well have been due to effects of alcohol. A rational treatment approach would be first to withdraw him from alcohol. deterrents are relatively few: some religions (for Mormons and strict Muslims). The tobacco companies attract new victims each year solely because their advertisements link cigarette use with beauty. or an anxiety disorder. For most drugs overall. another Axis I disorder. as is so often the case. the neurotransmitters dopamine and serotonin may also play a role in producing both the intoxication and withdrawal states from cocaine and alcohol. and fun. Which comes first chronologically is a help. and morphine. Stanley Monaghan may have been clinically depressed. In schizophrenia. the inherited risk for misuse approaches 50% of the variability. some have even suggested methods of treatment. cannabis.) From 10 to 15% of substance users have comorbid schizophrenia. depression. It is especially important to discredit the idea that people drink or use drugs just because they lack willpower or have weak characters. and the law (not very effective in western societies). especially schizophrenia patients. (In Asian populations a gene. had we evaluated Stanley for depression. identical twins are more concordant for alcoholism than fraternal. And an expanding literature suggests that alcohol and other drugs may increase endorphins. cocaine.

a physician’s urging to quit can be determinative. and stood at the front door. Court. and tobacco. especially if the urge to use is stronger than the desire to stop. can motivate a user to take action. it would encourage the patient to express emotions. after a prolonged courtship. Here is my first approach. (Alcohol free. Those we live with and love powerfully shape our behavior. Various means of assistance and coercion could play a pivotal voice in a user’s decision to change. Building on the history of. (Samuel Taylor Coleridge. Many corporations and government agencies offer professional help through voluntary programs. Persuading people to become patients can be difficult. if he resumed using drugs. and cognitive. anxiety. as have the professional diversion programs offered physicians as an alternative to loss of license. and smoke-free. it can be wrenching to assume the role of an authority figure and apply . thoughts. for several reasons we hesitate to apply pressure to save the lives of those they care for. for abuse. including mood. It uses evidence from the patient’s own history as persuasion to enter treatment.) Similar arguments could be made for a variety of disorders. the solution may be less readily achieved. That was the last time he used anything. she agreed to marry him—with the understanding that. any residual depression might respond well to CBT or another form of psychotherapy. Mass persuasion. for example. almost every time. Work/school coercion. Employee assistance. psychotic. Unhappily. The military has made especially effective use of this mechanism. a recent job loss or a ruptured relationship. sexual.” “Great thinking!”) until the patient’s everyday thinking finally begins to reflect these ideas. A critical mass (at least three or four) of relatives and friends. these principles are often easier to state than to apply. Nathan had habitually used alcohol. under 10%. The threat of job loss or academic expulsion can be a powerful stimulus for change. sober.”) There are a lot of factors working against you as you try to steer your patients away from the allure that can destroy them. and feelings about what might have gone wrong or how it might have been prevented. Children. cocaine. which refers to the appropriate page for complete diagnostic criteria. When the user is a minor child. marijuana.Substance Misuse 125 specific treatment for depression. Spousal leverage. all expressing the same—even unwelcome—truths. Frank discussion. For some habits such as cigarette smoking. These are summarized in Table 4. wrote of being “chained by a darling passion. 8 years later he is still clean. For other substances. Especially if the person is a parent or spouse. sleep. When he was 25 he met Nan. Patients who enter treatment in lieu of punishment for crimes or misdemeanors committed while intoxicated do about as well as voluntary patients. Three years later he slipped and began drinking. Sidebar: Getting Your Patient into Treatment Studies suggest that the treatment rates for drug dependence are under 40%. she take any children they might have and leave him. Throughout college. Any mention of the role of substance misuse would be immediately reinforced (“Good insight. who was a heavy user of opium throughout his adult life. a parent’s legal leverage to command evaluation and treatment is strong—assuming the appropriate professionals are available and affordable. after 2 weeks Nan packed up her bags and the baby.

this approach simply doesn’t work. we fear to tread where we are not invited. Because substance users also use denial. across the board to all substances. If your patient’s commitment to sobriety seems to waver. Again like Del. you might use motivational interviewing to highlight the conflict between life goals and substance use—for example. . but don’t be alone—keep your spouse or trusted (non-drug-using) relative or friend with you. and to probe the perceived causes of their use. including the inhalants. self-soothing (“If I don’t have a couple of drinks before bed. we may feel reluctant to confront an issue when there appears to be so little daylight between ourselves and the person who clearly has a problem. As for friends and coworkers. Because we know from experience that. I stare at the ceiling and worry”). • Clean house. you should interview collateral sources whenever you can. people have tried to limit substance use rather than eliminate it completely. It may be necessary to make a physical move away from associates. not of. Plan how you will change your lifestyle to avoid old habits. but for some substances. we stand on the sidelines and live in hope. and hallucinogens. This information may reveal another diagnosis—perhaps depression.Substance Misuse 126 pressure. The future depends on freedom from. that you want to be a good provider but. Another purpose of the initial evaluation is to assess motivation to change. social phobia. First (and always). • Deal with family problems. PCP. often don’t show up for work. Of course. places. I was the life of the party”). like Del. most casual substance users do not develop serious problems. substance use. The goals are to be sure that no medical disease has resulted from drug use. to assess how many substances are being abused and to what degree. which is essential to recovery. The plan for long-term treatment and prevention outlined below assumes that you have already cleared the hurdles of acute intoxication and withdrawal and any emergencies (suicidal ideas and severe infections are just two of the many possibilities). When another mental diagnosis (dual diagnosis) is found—which is the case in over half the people who misuse drugs and alcohol—it can impart another dimension to treatment. every last ounce of marijuana. The reasons include peer pressure (“All the kids back then were doing it”). because of drinking. • Change the environment. Shield yourself from drug-using friends. Relatives can facilitate the patient’s recovery by becoming involved in therapy and perhaps confronting their own drug or alcohol issues. for the vast majority of users. but they are time-honored practices that nearly every clinician will wholeheartedly endorse. Treating Substance Use Problems: General Approaches Some treatment principles apply universally. • Abstinence should be the chief treatment strategy. and situations that are reminiscent of drugs. For decades. and fun (“For the first time ever. Here’s a sample of what I’d advise my substance-using patient (and the family) to do: • Take a week off to organize your thinking. psychotherapies haven’t been explored—so we and our patients must rely on general principles. you should discuss these general treatment steps with your physician. there have no special treatment modalities—drugs haven’t been developed. take a complete history and obtain a physical examination. who once drove drunk. or another anxiety disorder. every hidden bottle. It’s far harder to stay off drugs if the person lives or works someplace that encourages their use. Encourage the patient to toss out every bit of drug paraphernalia.

Of these. frequent checks of urine specimens. the same clinician should treat both (all) disorders. for example. A proven psychotherapy technique such as cognitive-behavioral therapy is often the best approach. job training. Pills). Cocaine. and relatives can be brought into the campaign for sobriety. it should probably be treated along with the substance use. Patients reside at one of many facilities for 12 to 18 months.Substance Misuse • 127 • • • • • • • • • Join a 12-step program. They may provide transportation to and from shelters. and group meetings daily or several times a week. drug screening may help the patient comply with the program. secretive snorting and the like that eludes detection. and augment education. They provide role models. individual and group therapy. The threat of negative consequences (being fired or jailed. For many. even memorializing anniversaries with a cake or some other token of achievement. such as the VA domiciliary programs. support. Whereas the 12-step programs emphasize how long a person has been sober. If there is another diagnosis. antianxiety. A big risk for some is furtive use—closet drinking. Therapeutic communities work well for some people. receiving education. the cost is usually far less than hospital treatment. Even if the patient slips and uses again. and fellowship. Phoenix House is perhaps the best known. Whenever possible. Use antidepressant. The patient will need to learn alternative approaches to these situations. Although there is little research to prove their effectiveness. For some of the same reasons that the 12-step programs work so well. where the patients actually live. and lunch at the program. I prefer to focus on the percentage “good time” this year as compared to the year before. Friends. especially those who have no other mental disorders. Some reward compliance with vouchers that can be exchanged for useful products. such as a depression that persists many weeks beyond the time drug/alcohol use stops. so someone who needs to use pills or patches will have to shop around for a 12step group that meets these particular needs. Though expensive. neighbors. it isn’t a disaster. and they cost nothing but time. Patients slip all the time. for relapse is just a swallow away. but others. Some groups discourage all forms of treatment that involve medication. Some patients even authorize the therapist to report them if a urine tests positive for drugs. and the year before that. it’s the nature of the disease. may be less strict. They serve many problems and constituencies around the globe.” Work to identify cues that can trigger a relapse. After several months.” then follow through. Phoenix House allows no substitute drugs. moods. the patient’s job has only just begun. specific situations. or being around certain people. group therapy can increase social support. or antipsychotic medications only for an independent mental disorder. Narcotics. I strongly recommend the “Anonymous” programs (Alcoholics. If that has been the history. these programs may work better that conventional psychotherapy. But above all. “Stay sober. patients can graduate to paid work. Once clean and sober. . counseling. losing a professional license) provides a powerful incentive to stop using. Some of the most successful patients are those who commit to attend “90 meetings in 90 days. and work assignments. There is almost always something you can find to feel good about. decrease isolation. One of my most successful patients kept a daily to-do list that was always headed. Drug-free programs for cocaine and heroin users combine weekly individual counseling. don’t let a slip serve as an excuse to return to full-scale use.

the support from others facing the same challenges can provide an extra boost. • Nicotine gum may be especially helpful for those who smoke at certain times of day (for example. spray. Sidebar: Smoking Out a Habit Here are some steps that can help your patients find their way from the tobacco road. Table 5 summarizes some recent data on substance use prevalence. for starters. it can also address depression. “I was a hungry. As popular as is the patch. which quieted the withdrawal effects to the point that she could focus during her group support meetings. we’ll next cover the range of abused drugs. and emphysema. The 4-mg sticks may be necessary at first. Miranda’s GP suggested that she use a nicotine patch. After a week. Some therapists recommend rapid smoking to the point of nausea. irritable. about half of them eventually succeed. Some experts call nicotine the most addictive substance in the world. even light smokers tend to find the 2-mg sticks ineffective. Especially if this isn’t the first attempt. • Establish a quit date and stop abruptly.Substance Misuse 128 TREATING SPECIFIC ADDICTIONS Listed in descending order of popularity. Of all smokers. The consequences are almost too well-known to list in detail—lung cancer. or inhaler. but the data don’t show advantages over other methods.” she confessed later at a group support meeting. and it does present health risks. and restlessness. trouble concentrating. Zyban (the antidepressant Wellbutrin) has been shown to reduce weight gain and the craving for nicotine and to slow the onset of relapse. nicotine is the most deadly addictive substance in the world. if at all possible. she also described having insomnia. • Seek a therapist who can provide behavior therapy (there is good evidence for the effectiveness of reducing the cues that have meant smoking in the past. Nicotine In terms of the misery it wreaks. such as ash trays in the house and after-dinner coffee). and famished. • Patients who smoke heavily may do better with the patch. which cuts 7 years off the average life span. peer acceptance. Miranda felt depressed. some people prefer nicotine gum. In the days after she started her “cold turkey” withdrawal. heart disease. after meals. peaking at 2-3 days and lasting 3-4 weeks. Yet the attractions of tobacco use—glamour. sometimes only after many attempts. cranky witch. each year nearly half try to quit. its legal availability can make it harder for some people to quit than heroin. • Get into a group. Data show that using medication with behavior therapy afford the best chance of quitting (and of avoiding weight gain that so often accompanies quitting). Nearly half of smokers die of illnesses related to their habit. which is quite likely to recur in a person who was previously clinically depressed and who stops smoking. coffee breaks). . Nicotine withdrawal symptoms occur in about half of those who quit. feeling grown up—are strong enough lures to teens and preteens to make nicotine dependence our most prevalent mental disorder.

which induce rapid rise in blood alcohol. indistinct philtrum—the midline vertical groove running from nasal septum to mid-upper lip). Really heavy smokers may need to combine methods (for example. • G-I issues. It occurs especially when a pregnant woman drinks in binges. esophagus.Substance Misuse • • • 129 Because it is irritating. the ratio of male to female heavy users is around 4:1. marital separations. liver. arrests. • Korsakoff’s syndrome with lasting memory and cognitive impairment (perhaps a third improve with time and adequate nutrition). • Finally come social troubles. ataxia. small midface. And although the inhaler seems especially inconvenient. . stomach. of which alcoholism is the third leading cause in the United States. • A wide variety of physical findings. facial abnormalities (small circumference. ascites. here is a summation of what the Bard missed: • Drink-induced amnesia (blackouts). diarrhea. at least people don’t have to stand outside in the rain to use it. and pancreatitis. • Dementia. tongue. 4% for women. divorce. for someone who has tried repeatedly and failed to quit. Short of that. and bruises from falls. • Wernicke’s encephalopathy (thiamine) with nystagmus. confusion. From head to toe. the problems are many and varied. Also of course. cancer of mouth. • Fetal alcohol syndrome: Low IQ. which can occur relatively early in a drinker’s history.] • Though smoking probably also plays a role. subdural hematomas) and over half of all motor vehicle accidents. Shakespeare once observed that people “put an enemy in their mouths to steal away their brains. • Depression occurs in over half of dependent drinkers. the ultimate sequel is death. Dupuytren’s contractures. patch plus spray). Substance use is defined by the sort of problems it inflicts upon the individual and those around them. esophageal varices. including gastritis. and male breast enlargement occur late. Jaundice. and pancreas. testicular atrophy. And. In the case of alcohol. I’d avoid the nasal spray. loss of job). alienation from friends and family. the lifetime risk of serious alcohol use problems is about 10% for men (who also begin earlier). cachexia from malnutrition. except as a second trial or a helper for the patch. lateness. [More about this in depression chapter. • Accidents (which include falls leading to bruises.” Too bad he didn’t also note how far beyond the brain extends the scope of health problems induced by heavy. you might consider augmenting the patch and behavior therapy with bupropion. liver enlargement. epicanthic folds. chronic alcohol misuse. not as single spies but in battalions: employment problems (absence. fractures. Alcohol With an onset in the late teens or early 20s. • Ataxia and trouble speaking from cerebellar damage. which are both characteristic and classic: palmar erythema. larynx. Around 3% kill themselves. • Impotence.

simple withdrawal shakiness subsides after about a week. if the patient cannot swallow tablets). but hospitalization will be needed if the patient cannot comply. decades of research have produced no conclusive evidence that inpatient care improves outcome. the patient hears voices that may be threatening. DTs lasts about 3 days. though adequate lighting will help reduce visual misinterpretation (illusions). Severely affected patients may require help even to drink a glass of water without spilling. or complications obtain such as other psychiatric illnesses. they don’t require anticonvulsants. which typically beginning 7–38 hours after the last drink. which occurs in about 5% of hospitalized alcoholics. In the old days. death ensued in up to 15%. Withdrawing from heavy alcohol use General management of alcohol withdrawal includes adequate hydration. Symptoms of marked autonomic instability include fever. The GGT changes rapidly enough that it can be used to monitor ongoing abstinence. A typical drug regimen would be 10 mg of diazepam IM. Beginning within 48 hours of the last drink. withdrawal can be done on outpatient basis. Other than short-term use of benzodiazepines. and talking to animals or Lilliputian people lined up on the windowsill. and anxiety. disorientation. Diazepam can then be tapers over the next few days. perhaps in heavy doses. though some require a benzodiazepine such as chlordiazepoxide (Librium). However. and illusions/hallucinations. there are no supports at home. rapid heartbeat. A healthy person who isn’t heavily dependent. followed by 5 mg every 5–15 minutes until agitation recedes. There are several of these. up to a week. agitation. As opposed to the delirium of DTs. these withdrawal hallucinations are auditory and occur in the context of a clear sensorium. and reacts accordingly. With or without treatment. The classic image is of the patient who lies in bed. some patients will require restraint. Rehabilitation and relapse A person with other medical problems or a past history of severe withdrawal symptoms may require hospitalization for several days. Seizures Long-term heavy drinkers are especially prone to withdrawal seizures. This is a withdrawal delirium whose symptoms include insomnia. elevated blood pressure. nausea or vomiting. insomnia. seclusion may be necessary. vitamins (especially Thiamine 100 mg — IM. to prevent even more serious withdrawal symptoms. MCV and GGT (gamma-glutamyl transferase) are elevated. A heavy drinker like Stanley could experience a number of typical withdrawal symptoms: Tremors Withdrawal shakiness (“the shakes”) begins after 12–18 hours and peaks between 24–48 hours. with good care. nearly everyone survives today. with a 5-day taper. in most alcoholics. Hallucinosis Alcoholic auditory hallucinosis is uncommon. To reduce agitation. . at most. food. especially if this has worked previously. Severe hallucinations may require a low dose antipsychotic such as haloperidol. Often. Tremor may be joined by other symptoms that include sweating. may be able to stop with mild symptoms. but dramatic. picking at the bedclothes with tremulous fingers. and benzodiazepines such as 25–50 mg chlordiazepoxide qid. Duration is about a week. Delirium tremens (DTs) Withdrawal seizures alert us to the possibility of delirium tremens. though a neurological consultation would of course be in order. like Eva.Substance Misuse 130 And Ye Olde Stratford Lab would have verified that. tachycardia. unless there are serious withdrawal symptoms.

and no family history of alcoholism. Disulfiram causes the body to metabolize alcohol into acetaldehyde. occasional use is relatively harmless— certainly. heavy use can slow emotional and social development. it has been found to decrease alcohol craving and euphoria. The other points out that drinkers often smoke. Half-life ~2 days. But the likelihood of eventual success improves with treatment and stable relationships and the responsibility of a job. The relapse rate for dependent drinking approaches 50%. heavy use causes what’s called the “amotivational syndrome”—apathy. Although any smoking is bad for your lungs. It reduced her sexual inhibitions like alcohol. Naltrexone. However. The risk of toxicity largely causes clinicians to avoid its use anymore. As for therapy: although nonspecific psychotherapy hasn’t proven very helpful. poor concentration. perhaps a few times in a month. Only rarely are there untoward mental or physical effects. but it can help prevent slips in someone who is well motivated. social withdrawal.Substance Misuse 131 Three drugs can help maintain sobriety: Acamprosate (Campral). There is some evidence that two drugs taken together are more effective than either taken individually. Robin liked marijuana because it made her feel relaxed and contented. Effects in a few (10-30) minutes. Should someone who uses both tobacco and alcohol heavily try to quit them at the same time? There are two points of view. which induces almost immediate nausea and other physical symptoms. Marijuana The upper leaves. anxiety may necessitate treatment with diazepam. half of high school students have tried it. Personally. lasts 2-4 hours. Acamprosate’s mechanism of action isn’t exactly known. far less a problem than most other illegal (and some legal. so that stopping both should reduce the cues of one that stimulate use of the other. and loss of interest. and disulfiram (Antabuse). which blocks brain opioid receptors. In addition. some patients may benefit from learning social and coping skills. lack of antisocial personality disorder. she would sit back and enjoy dreamy fantasies. and the smoke is inhaled deeply and held in the lungs as long as possible to absorb the maximum possible amount of THC (delta-9-tetrahydrocannabinol). neither of which is backed by much science. Marijuana is used regularly by 20 million or more Americans. Hashish is the dried resinous exudate that collects on the tops and undersides of leaves of female plants. Marijuana is acutely dangerous if you’re pregnant. especially in first 6 months. Marijuana is most commonly used like alcohol—to facilitate sociability. the percentage of teenagers who have tried marijuana in the past year has remained relatively stable at about 35%. but without the hangover. After smoking. flowering tops. Then. see Sidebar) drugs cause. nursing. but the effects more powerful. Those who don’t smoke sometimes eat it in brownies. during which time seemed to stand still. have heart . it may reduce the dysphoria and sleep disorders that accompanies a heavy drinker’s prolonged withdrawal from alcohol. has been used for years to combat acute narcotic overdose. and stems of cannabis sativa are made into cigarettes. Although worldwide marijuana is the most commonly used of all illegal drugs. cognitivebehavioral therapy has. I’d work first on the more immediately destructive alcohol. in which case the onset is slower. One argues that quitting alcohol alone is hard enough and that the social and physical effects of alcohol are more immediately destructive—so keep on smokin’. naltrexone (ReVia). over the past two decades. less severe comorbid disorders. In teenagers.

) Cocaine is the most powerful reinforcer of drug-taking behavior known. That can make it hard to persuade your teenage patient that there is a problem. Most marijuana users probably don’t need treatment any more than people who drink alcohol occasionally. as a smokable. It may take weeks for thinking. Heated with sodium bicarbonate. anxiety symptoms during use or in a flashback are by no means rare. mood. famously. he would rouse himself and start using again so that once more he could feel wonderful and self-confident. It seemed to enhance his social life (he felt bright and witty and had “dynamite” sex). it was little abused in the United States. Terry started using cocaine occasionally with friends. during which they consume the drug several times an hour. Laboratory rats prefer it to food. If marijuana is used frequently. and sleep to normalize. with dreams of destruction so realistic he would awaken screaming. he smoked crack again and again. until it is gone. Cocaine produces intense devotion and high recidivism. but westerners first used cocaine a little over 100 years ago. Withdrawal is extremely rapid. Perhaps a quarter of 21st-Century young people have tried it. Although there is no actual withdrawal syndrome. he used it every week or two without problems. it was the eponymous ingredient of Coca-Cola. it is safer to use than freebase yet also produces a powerful rush of euphoria. has been implicated in numerous deaths. don’t go on to abuse other drugs. at the dawn of the 20th century. and usually requires no special treatment. The vast majority of people. (Users sometimes intensify their experience by adding other drugs—cocaine plus heroin. It is an . water. no cause-and-effect relationship has ever been satisfactorily demonstrated. chronic use causes long-lasting changes in the brain and memory loss. Consult DVDs of the TV series “The Wire” for details. the accompanying depression can be so profound that the person will do just about anything to escape. a combination called a speedball. Hospitalization may be necessary for someone who is suicidal. Although it has been argued for years that marijuana is a “gateway drug” that leads to the use of other. or who has had previous unsuccessful attempts at rehabilitation. and the company of other rats. or injected IV. to the exclusion of other activities. Cocaine can be swallowed. elevating mood and increasing alertness and confidence. indigenous peoples have chewed coca leaves as a stimulant. they’ll use it until they die of starvation. snorted. generally less severe than with opioids or sedatives. or driving a car. until his supply was gone. Cocaine For millennia. more dangerous substances. and has been wildly popular since the 1980s. For a semester. but during summer vacation. like Robin. Haptic (tactile) hallucinations can be experienced during cocaine intoxication. After a few days. benzodiazepines may occasionally be needed short-term to deal with anxiety. Then he would fall into a depressed torpor. group therapy that focuses on drugs probably helps most. Especially when smoked or injected. severely depressed (sometimes psychosis supervenes). given free access. However. users (like Terry) escalate to intense runs.” Crack is cheap and powerful. frequent users may feel irritable or have trouble sleeping. Human use is nearly as devastating. cocaine yields a hard white mass that makes a crackling sound when smoked. A better case for gateway status can be made for tobacco. cocaine creates a powerful rush of pleasure. Until the 1970s. inhaled.Substance Misuse 132 or lung disease. Though usually intermittent at the start. In his third year of college. hence the term “crack.

Obtaining amphetamines can occupy a person’s entire attention. Others use them to produce euphoria. punctuated by periods of crashing. Paranoia and overt psychosis. to get clean and stay that way. perhaps moving on to very high doses. Terry joined Cocaine Anonymous. talkative. General treatment approaches can liberate many users. smart. (You won’t find that featured in the psychoanalytic literature. making them attractive to truckers and others who drive for a living.) In 1937. He recovered. From 1942 until his death. often by inhaling. obliterating all other considerations and responsibilities. on average. in 2000. Now used for many years by psychiatrists and other physicians for AD/HD. amphetamines today are prescribed for attentiondeficit/hyperactivity disorder in children and narcolepsy in adults. Withdrawal from low doses yields relatively brief fatigue. Users feel strong. and even now he sometimes thinks how wonderful he would feel if he could smoke a single rock of crack. Experienced users sometimes add sedatives or alcohol to moderate the effects. it is a vasoconstrictor used in Vick’s and other nasal decongestants. the generic . legally marketed as Desoxyn. Hitler took daily amphetamine injections.Substance Misuse 133 irony that Sigmund Freud once recommended it as a treatment for alcohol or morphine addiction. (It was sold without prescription for that purpose until 1965.) Education or pressure from relatives or employers can motivate some people who are not heavily dependent to give up the habit. In the United States. and preoccupied with getting more drug. Many occasional users stop without treatment. hospitalization is indicated only if the person becomes severely depressed. The symptoms of intoxication and withdrawal are nearly identical to those of cocaine (see Table). psychotic. from higher doses. but other studies have failed to find any advantages. users become restless. Structurally related to adrenaline. One study suggests that heavy users may improve with the combination of group and individual drug counseling based on 12-step programs. Charles Bradley found that amphetamine caused nearly half of behavior-disordered children improved and also showed an improvement in school performance. or the intake is far beyond control. narcolepsy. by which time its potential for abuse had become too great to ignore. violent. though it took more than a year. (The l-isomer possesses little central effect. a controlled study found it better than two other treatments. is prescribed for AD/HD and exogenous obesity. even death (from stroke or heart failure) sometimes ensue. Some addicts (and their therapists) swear by earlobe acupuncture. including jobs and children. Relapse prevention therapy (see page *) has been especially successful. dextroamphetamine is the perhaps best-known of these compounds. irritable. when it was marketed as Benzedrine in an inhaler for relief of nasal decongestion. and his parents paid for a course of RPT. though it takes nearly 2 years. The d-isomer. the amphetamine molecule languished unappreciated until the early 1930s. Methamphetamine The chemical structure of methamphetamine is identical to amphetamine except for a methyl group clinging to the nitrogen. Amphetamines and Other CNS Stimulants First synthesized in 1887. which may have affected his conduct of the war. What do these drugs so appeal to recreational users? They fend off fatigue. and sexy. leading to speed runs of days or weeks. and they are even occasionally useful in depression. Clinicians also prescribed amphetamines for disorders as widely varying as impotence and appetite control. and (sadly) weight loss.

Like Miriam. “It wasn’t scary. the former mayor of Cave Junction. The symptoms are mainly positive. methamphetamine is notoriously popular with kitchen chemists. psychosis. Nearly 100 such plants have been recognized in the Western Hemisphere alone. Waddell’s defense was that of methamphetamine-induced psychosis: high on crank. Methamphetamine’s central effects are even more pronounced that those of amphetamine. Miriam found that colors seemed brighter. It is so easily made in home laboratories. Hallucinogens The ability of natural substances (such as mescaline and the fly agaric mushroom) to produce hallucinations has been recorded throughout history. many users value it for its rapid onset of mild euphoria and sensory distortions. these patients are typically agitated and may require antipsychotic medication. so as not to raise the alarm of prospective cold sufferers. For several months afterwards. Flashbacks also occur. especially visual hallucinations and nonbizarre paranoid delusions. There are no withdrawal symptoms as such.Substance Misuse 134 term used is levmetamfetamine. but I sure wanted it to go away. anxiety. Ironically. he heard voices and believed that Green was conspiring with the CIA to have him killed. then set it on a shelf. Oregon. the LSD experience usually resolves spontaneously after just a few hours. such as peyote. Oregon and other jurisdictions have relegated ephedrine and pseudoephedrine to behind-the-counter availability. Albert Hofmann synthesized lysergic acid diethylamide (LSD) in 1938 from ergot alkaloid. and once she thought that people she encountered at the mall were automatons. When high. or suicidal ideas. In 2007. though Klonopin or Valium may occasionally be needed to calm someone who is coming down from a bad trip—as with Miriam’s friend. PR rules!) Despite its availability through legal channels. Because it can be made from readily available materials. When patients seek treatment. Because frequent use weakens its effects.” and she had never experienced one of those bad trips that a friend once described—he was terrified. She always knew that these sensations weren’t “real. emotional stressors.” With its duration of effect 8–12 hours. Known on the streets as crank. For example. sounds clearer. Then an unresolvable . If hallucinations persist. and over-the-counter drugs. it can occasionally cause marked anxiety and paranoia. hence so cheap. some of these traditional botanicals. without further drug use. antipsychotic agents may be necessary. it is usually for depression. that it has found a wide clientele. provide the basis for religious rituals in indigenous populations. most people don’t use LSD day after day. LSD is perhaps 5000 times as potent as mescaline. During her dozen or so experiences with LSD in college. Not everyone has a green thumb. marijuana. half or more of frequent users report flashbacks—aspects of a previous trip replay themselves spontaneously. That frightened her into quitting. the user should avoid stimulants. As you might imagine. so there is little tendency toward dependence. feared he was going insane when he seemed to melt into the boundaries of the universe. Miriam would occasionally see bright colors around the edge of the paper she was writing on. so it is perhaps not surprising that would-be users have turned to chemistry to meet their needs. tastes sharper than normal. It wasn’t until five years later that he returned to discover its psychedelic properties. it can produce a severe psychosis that begins hours to days after the onset of heavy use. a young homeless man named Timothy Waddell beat to death Tom Green. Green himself had at one time worked as a chemist.

. dehydration. She was lucky: a 2001 study found that MDMA users can suffer long-term cognitive impairment. alpha-methylphentanyl (China White). tachycardia. when she accepted a drink from someone she didn’t know. with short-term amnesia followed by restlessness and general discomfort. * . An overdose can cause fever. One. Her drowsiness.Substance Misuse argument often erupts: was the long-term psychosis caused by the drug.4-methylene dioxy methamphetamine). and fatigue lasted for several days but subsided without any specific treatment. Then someone grabbed her and hustled her into the cool-down room. it boosted her self-confidence so high that she grabbed the microphone and started to sing. Designer drugs are chemicals that have been manufactured to get around substance use laws. MDMA is classified with the hallucinogens. trouble concentrating. 135 MDMA (Ecstasy) Though actually an amphetamine derivative (3. At first. or would it have occurred anyway? Most experts would vote the latter belief. Jenny encountered Ecstasy at an all-night rave party. arrhythmia. One of the so-called designer drugs. these are minor variants of amphetamine or opioids—e. Often.g. has caused severe parkinsonism in some users after just one hit. followed by depression.* it makes people feel euphoric and close to others. and even death. MPTP. where she gradually succumbed to anxiety bordering on panic.

bufotenin (originally extracted from toad venom) Rx only. communities. and health-care costs. Blakemore C: Development of a rational scale to assess the harm of drugs of potential abuse. including intoxication.g.g. laudanum. Here.g. opium preparations such as Kaolin Pectin P. and society. Lancet 2007. e. is an alternative view from a recent Lancet article* on the relative harm of 20 drugs.Substance Misuse 136 Sidebar: Drug schedules in the United States Since 1970. and the effect of use on families. amphetamine salts (Adderill) for ADHD. fentanyl. LSD. opium and its tincture. importation. *Schedule I: In addition to above criteria. psychological dependence. a synthetic form of THC Schedule IV Lower than III Yes Limited physical or psychological relative to III Rx only 5x in 6 months Benzodiazepines. codeine. **except for cancer patients and burn victims. Motofen. in which each rater scores each drug independently. — No — Gammahydroxybutyric acid (GHB). * Nutt D. The act has been amended several times in the past 40 years. and physical dependence. PCP.. Xyrem (GHB) for treating narcolepsy. heroin. dihydrocodeine. pentobarbital). distribution. Misuse potential Accepted med. zolpidem and other “Z” sleepers. methadone. methaqualone. methylphenidate (Ritalin). phenobarbital and other longacting barbiturates. King LA. Robitussin A-C. through the Controlled Substances Act the Federal Drug Administration has regulated the manufacture. pentazocine. dronabinol (Marinal). possession and use of certain drugs. hydrocodone (dilaudid). chronic.. Saulsbury W. and intravenous use. cannabis (!).369:1047-53. dextroampheta-mine. secobarbital and other short-acting barbiturates (e. MDMA (Ecstasy). which includes acute. and raters are then given the opportunity to changes their individual ratings. use? Dependenc e: Use may lead to… Legally available? Refills Sample items Schedule I* High No Schedule II High Yes Severe physical or psychological Schedule III Less than I/II Yes Moderate or low physical or high psychological Rx only 5x in 6 months anabolic steroids. psilocybin (mushrooms). which includes the intensity of pleasure. however. The authors posited 3 categories of harm: Physical. propoxyphene (Darvon). ketamine. paregoric.G. . Modafinil Schedule V Lower than IV Yes Limited physical or psychological relative to IV Only for medical purposes * * Codeine preparations. then the group discusses the findings. the tendency to induce dependence. difenoxin e. buprenorphine. Harm was assessed using Delphic principles. other social harms. 30 days** no Cocaine (topical). these substances have “a lack of accepted safety for use of the drug or other substance under medical supervision" whatever that may mean.

Reduce by a third on the second or 3rd day. start with a ten to 20 percent decrease over the reported daily dose and observe for signs of withdrawal.08 1.66 1.70 1. a longer-acting drug (such as diazepam) is used. if tolerated.58 Cannabis Solvents 4-MTA LSD Methylphenidate Anabolic steroids GHB Ecstasy Alkyl nitrites Khat* Overall harm 1. an amphetamine-like stimulant that causes anorexia. reduce 10-20% further every few days. Again. the criteria for intoxication and withdrawal are identical. the danger of death by respiratory depression is attested by Marilyn Monroe.80 Sedatives With symptoms similar to alcohol.62 1. Still. Patients with a year or more of use may require months for their taper. though some clinicians will taper with the actual drug the patient was using.27 1. and Princess Leila Pahlavi of Iran.09 0.15 1.23 1.12 1. Jim Hendrix. . The general steps outlined above can help most long-term benzodiazepine users successfully stop and stay off. the symptoms of benzodiazepine misuse are far less severe than those of most other drugs. benzodiazepines have been hugely popular. in some cases with less anxiety that when on the drug. taper it after the benzodiazepine is gone. and excitement. On the other hand.74 1. It contains the alkaloid cathinone. Judy Garland. A patient who has taken a benzodiazepine longer than 2 weeks should be tapered. and those who do misuse them often use other drugs as well. intoxication and withdrawal are symptomatically very similar to alcohol. especially with the over-55 crowd.18 1. Carbamezepine 400 mg/day (either bid or at bedtime( may help relieve symptoms of withdrawal. adequate substitute treatment (such as psychotherapy or antidepressant medication) is extremely important.27 1.92 0. but strict government controls have led to marked declines in their misuse. * Tropical flowering plant found in East Africa and the Arabian peninsula. and the response to treatment is far better.30 2.33 1. Charles Boyer. often in combination with alcohol or other drugs. for a variety of indications. even in massive overdose. Mostly. benzodiazepines are used appropriately. Barbiturates and other dangerous sedatives were heavily abused in the 1960s. Because many patients are prescribed benzodiazepines for anxiety and other disorders. even death. For the most part. in a small percentage.85 1.94 1. Studies show that most patients can come off benzodiazepines successfully.Substance Misuse 137 Overall harm Heroin Cocaine Barbiturates Street methadone Alcohol Ketamine Benzodiazepines Amphetamine Tobacco Buprenorphine 2. all of whom died as a result of using secobarbital or some other barbiturates.77 2. Rarely lethal. euphoria. withdrawal can precipitate seizures and.

solvents in glues. and then I must have passed out. including brain. Their wide availability and low price make them a natural for kids. and propellants for paint. a few people even die from inhalant use. misuse any of the opioids*. to increase sexual compliance and reduce memory in unsuspecting victims. users absorb them through their lungs. Dudley had huffed model airplane glue for 3 years. doesn’t heroin usually spring first to mind? Although people can. often with alcohol. and oxycodone. to get the victim to some place safe to recover. methadone. Patients (and their doctors!) should avoid punch bowl concoctions. the fate of perhaps one in four who ever try it.” 138 Whether facilitated by rohypnol or some other drug (evidence suggests that other benzodiazepines are about as likely to cause mischief). At a party. Because these CNS depressants severely reduce the blood’s ability to carry oxygen. Inhalants Inhalants present something of a contradiction: illicit drugs of abuse that were perfectly legal when originally sold as fuels. fentanyl. The next clear memory I have is waking up in his bed. meperidine. education may be all the discouragement needed. even to use the bathroom. if needed. Weekly use usually leads to dependence. most addicts prefer heroin. Because they evaporate easily. the inhalants can cause widespread destruction of the body’s tissues. and muscle. “The last thing I remember was swallowing the drink Ronnie gave me. Those who persist should be referred for longer recovery programs that use a variety of treatment modalities.” Cynthia told the policewoman who interviewed her. but I couldn’t be sure. For those who use them only occasionally. It is fortunate that few people actually become physically dependent on them.Substance Misuse Rohypnol In recent years. semisynthetics (such as heroin). and he was raping me.” each to observe the other for symptoms of appearing too drunk and. he liked the high and the way it made the hours flash past so he didn’t think about the way his parents were always fighting. the benzodiazepine Rohypnol (flunitrazepam) has become notorious as the “date rape” drug. Legally prescribed for sleep in many countries. I think I woke up once. Although the effects are brief—a few minutes to under and hour—repeated often enough. who often use inhalants as a group activity. date rape can be best prevented by a combination of education and vigilance. liver. and hair spray. kidney. either method can keep a user high for hours. so-called roofies have been smuggled into the United States and used. “A few minutes later I felt dizzy and sick to my stomach. the severe dangers of chronic use will make any chronic user want to use all the treatment steps mentioned above as soon as possible. shaving cream. . The risk seems especially high in underprivileged children an in those whose parents use substances. Watch your drink being mixed or drink only from a sealed container. especially grade-school and teenage boys. either by bagging (inhaling from a container into which the substance has been sprayed) or huffing (mouth-breathing through a soaked rag). and synthetics (including codeine. and never leave it unguarded. enlist a friend as a sort of two-person “neighborhood watch. paint thinners. and do. Opioids When you hear the word addiction. * The opioids include naturally occurring opiates (such as morphine).

With adequate doses (often 60 mg/day or more). perhaps encouraged by peers or as a progression from other drugs. The federal government closely regulates maintenance by methadone. many heroin users require drug maintenance if they are to remain clean. insomnia. which feature frequent outpatient groups. which can help suppress the aches. Those who genuinely want to rid themselves of heroin dependence must commit to long-term changes of lifestyle. and AIDS. To qualify for such a program. it maximizes the euphoric rush. and pursuit and use (“staying well”) quickly come to dominate their lives. Though I know of no absolute proof of their effectiveness. and to do that may require withdrawal using methadone or clonidine. though its advantage may lie simply in having supportive relatives who are committed to rehabilitation. There is high comorbidity from other mental disorders and from such physical conditions as HIV and hepatitis C. injection is the more common way to take the drug. he applied to a VA clinic and began methadone maintenance. I’d consider any or all in the rehabilitation of an opioid user. which must be given in a licensed treatment program. He had lasted less than a week in several drug-free programs.) Although some users snort heroin. restlessness. muscle cramps. and craving. . but they can be extraordinarily uncomfortable and discourage dependent users from quitting. using other means. especially from overdose. a process that can take several weeks. here they are treated by ex-addicts as well as professionals. Then the problem is to decide how best to prevent relapse. Erik was a 42-year-old Army veteran who had started using heroin with a lot of friends when he was overseas in the army. most start in their teens or 20s. the sense that all is well. On 70 mg a day he rapidly stabilized. he admitted his mistakes and redoubled his commitment to staying drug free. Back home. Family therapy can help. due in part to the relative availability of drugs. The medication will be tapered gradually. but Erik’s paychecks “and a lot else” continued to go into his arm. tearing. and crime. Beginning within 10 hours or so. * Symptoms of withdrawal are outlined in Table 3. Finally reduced to selling drugs and burglarizing cars for stereos. (Healthcare professionals are also at high risk. once more gainfully employed. suicide.* The typical habit costs $200 a day. patients must have been dependent for at least 1 year and failed to quit. most patients experience decreased illicit drug use. Narcotics Anonymous. That’s why many patients can use it successfully to relieve drug craving and keep them from using illicit opioids. insomnia—are hardly life-threatening to healthy adults. friends. as revealed by his urine samples. you can use benzodiazepines to aid anxiety and sleep. In mild withdrawal. methadone little kick and a slow withdrawal. as you might expect. depression. Because of its long half-life. Counseling. lethargy. unemployment. his friends all quit. Although once or twice he relapsed. Ironically. and cognitive-behavioral therapy all seem to help many users. Tolerance begins within a few doses. even location—it may be impossible to stay off drugs if exposed to reminders of former lives. The first step is to get off drugs. Some manage with drug-free programs. Two years later he was still on methadone but otherwise clean and sober.Substance Misuse 139 Although some people begin to use when they are given narcotics for pain. the overall death rate is enormous. some move to therapeutic communities for periods as long as 18 months. withdrawal symptoms—nausea. which users earn by theft or selling drugs or themselves. The term cold turkey may derive from the look and feel of a turkey plucked and waiting to be cooked.

then withdrawn from the sedative—by far. To ingest this drug voluntarily is the utmost in human folly. we shouldn’t give up on someone who has tried unsuccessfully to quit: multiple treatment attempts can add up. Yet. Buprenorphine. is taken as a sublingual tablet and can be prescribed by individual physicians who have had special training. drowsiness and disorientation. The chances of eventually recovering from opioid dependency actually aren’t bad. Both it and methadone work well in adequate doses. hostile and rigid. so most clinicians argue that there should be no arbitrary limit on length of maintenance. but of course. hallucinations and paranoia. it’s effects are highly unpredictable. there are a couple of options. definitive treatment.Substance Misuse 140 An important negative is that withdrawing from methadone is uncomfortable and can take many months. Stable employment and supportive relatives generally improve the likelihood of anyone’s success. coma. Benzodiazepines and antipsychotics (those that are weakly anticholinergic. PCP starts working within 5 minutes and peaks in half an hour. without which there is less drive to use heroin. but if you go by the utter destruction it can cause. sedative withdrawal is the more dangerous syndrome. And. though methadone may have the edge in low doses. Its principal use has been in the treatment of alcohol dependence. but there is no known. But for many others. and eventual death sometimes results from respiratory depression. Smoked. which is most likely to occur within the first 3 months. a mixed opiate agonist-antagonist with a long half-life. like most of Erik’s friends. Life crisis or depression often heralds relapse. Originally an animal anesthetic. Without it. PCP is a calamity lying in wait. 75% or more of patients return to illicit use. even without special treatment. soldiers tend to stop using after returning from a combat zone. or “angel dust”) isn’t such a serious problem. Overall. eventually leading to success. Patients who use both sedatives and an opioid should first be stabilized with methadone. It has led to chronic psychosis. Naltrexone (ReVia) is an opioid antagonist that blocks euphoria. secluded for weeks at a time because any stimulation launched him into a violent rage. Physician’s Approach to the Substance Use Patient (and Family) Working with the patient Here are some of the precepts I try to keep in mind when working with substance-using patients: . There is evidence that any drug is more likely to be successful if combined with a psychosocial treatment. For example. or swallowed. the most important predictive factor is the strength of motivation. the outlook is less bright. Most people who use PCP recover—though one man I knew remained strapped to a hospital bed. phencyclidine (PCP. such as risperidone or haloperidol) may be useful for agitation. It can produce euphoria or panic. snorted. and convulsions. Nystagmus is characteristic. a professional person (read: healthcare worker) whose license to practice depends on remaining clean and sober has a powerful reason to clean up and stay that way. that brings up the chronic questions of cause and effect. PCP Judging just by the numbers of patients affected. Many people shake the habit. the strict demands of a spouse or partner may serve the same function. For patients who can’t find a methadone program or don’t qualify.

Boredom is an enemy of sobriety. Don’t express alarm. It often takes repeated * runs at the * before *. distaste.”) Don’t measure success by duration of total abstinence but as percent time spent substance free. Don’t argue with someone who is intoxicated. especially when some substance users are adept at putting the blame everywhere but on themselves. and eschew reproach. Whenever possible. in the office. Don’t hesitate to be frank. You don’t have to be harsh. Vigorous exercise. taking multiple vitamins. the points I like to cover include: • First (I remind them). Don’t dismiss treatment options. a patient will call up with concerns that you’ve dealt with. Working with the family And in talking with your patient’s relatives and friends. using condoms). For kids. and all the other perfectly normal emotions you may be feeling. just because they haven’t worked in the past. don’t make major changes. Your patients have experienced them all—their own and from family. and it can lead to disaster. Read books and magazine articles. Encourage participation in a 12-step program. But these patients need to feel more responsible for their own actions. This guilt can be hard to shake. uses behaviors that are the acme of the childish and self-defeating. Encourage participation in new activities as a substitute for drug use. (“You’ve had a lapse. counsel eating regular meals. • Join an Al-Anon program to learn what other supportive steps might be taken. You’ll get nowhere until the patient sobers up. or even critical. A lot of each will be needed to get past the demoralization (“What’s the use?”) so many drug users experience. forthright discussion of behaviors and their consequences might help to break through the protective wall of denial your patient has erected. I always bring up this option early—and often. or tried to. • Learn all you can about the substance. It’s hard for anyone to remain strong while feeling guilty. If you cannot get the person completely off drugs or alcohol. When the patient is high is no time for a confrontation —it simply won’t register. ask him/her to make a return appointment to see you in the office. horror. after all. • Wait until the return of sobriety to resolve differences. Repeatedly express your support and belief that treatment can help. and they don’t need to hear the same thing from you. day-out behavior that they see as destroying their relationships. These programs can help relatives cope when feeling worn down by the dayin. It will happen especially on the telephone when you’re on call. do what you can to reduce harm (for example. I’ve known people who violated these rules (sometimes all three at once!). for example.Substance Misuse • • • • • • • 141 • • • • • Practice acceptance. or move. it isn’t your fault. not less—so don’t treat users like children. and we’ve identified another situation that’s dangerous for you. It is so easy to talk down to a substance user who. not a relapse. attend lectures. so we sometimes feel reluctant to bring up discomforting subjects. Other than quitting your substance use. produces a “natural high” without harmful side effects. accompany your relative to medical and counseling sessions. don’t change jobs. there’s Alateen. get a divorce. Clinicians have the same feelings as anyone else. Specifically. . surf the Internet. but a calm. Regard slips as an educational opportunity.

it will help to establish them as an allies. not arguments. including the spouse. irritability. The consequences of continuing drug use must come across as information. or drugs must maintain a substance-free home and avoid these substances themselves. They’ll also have to deal with their own resentment. For just one partner to quit while the other continues to use is likely to destroy the sobriety. who need to learn that they are not to blame and that their anger at the user is normal. Someone who remains with an abusive user endangers all the family. not a life sentence. Education and frank discussion can help sow the seeds of sobriety now. Ask relatives to read this sentence until they believe it: Overwhelming evidence proves that substance abusers are sick. Learn to meet denial or lies with facts. friendly manner. The purpose of denial is to avoid feelings of guilt and shame. Help them learn to explain calmly (when the partner is sober) that the relationship won’t last if drug use continues. redouble your efforts to help her avoid all drugs. It can be a terrific opportunity to deal with enabling (unconsciously shielding someone from the consequences of drug use). the relationship. Nonusing spouses should be supported when they contemplate leaving the relationship. and indeed the patient. Studies show that recovery is strongly reinforced by support of family members. family. and cravings once their relative is off drugs. ensure the safety of all parties. not bad. or both. . not as a threat. If relatives can learn to present facts in a calm. but this is a statement. even if their own use is moderate. Consider recommending family therapy.Substance Misuse • • • • 142 • • • • • • Listening to reasons for using doesn’t mean that you agree with them. If there has been any history of violence. and may make treatment seem less urgent. If your patient is pregnant. Spouses who want partners to quit using alcohol. many of which can seriously affect the survival and health of the developing baby. tobacco. Prepare the family for depression. Is the patient worried that their children may take up the use of drugs? The relatives of drinkers tend to drink.

increased activity.Substance Misuse Tables TABLE 1. or anxiety. increased appetite. tremors. job. tearing or runny nose. anxiety. poor memory or loss of concentration 4+ of: dysphoria or Depend depression. belligerence. social. though flashbacks (hallucinations that persist after the drug is out of the system) can occur N/A Depend/ Abuse Depend/ Abuse Mariju ana N/A Depend/ Abuse Euphoria.1 poor memory. poor concentration. school. impaired job or social functioning Physical/cognitive sx during intoxication 1+ of: slurred speech. yawning. reduced inhibitions similar to alcohol. blunted mood. poor coordination. unsteady walking. diarrhea. vivid bad dreams. nervousness. fatigue. agitation. or other functioning. glamour. impaired judgment. psychomotor agitation Perceptual changes plus 2+ of: dilated pupils. rigid muscles. . psychomotor activity speeded. Abuse muscle aches. unpredictability. sleeplessness N/A Depend/ Abuse Nicotine Euphoria. impaired job or social functioning Apathy. interpersonal sensitivity. vomiting. polyuria. changes in sociability. seizures * The symptoms aren’t caused by a general medical condition nor better explained by another mental disorder. slowed reflexes. Within 2 hours of use. dreamy fantasies Initially. assaultiveness. relief from fatigue. unsteady walking. blurred or double vision. sensation rapid heart rate that time has slowed down N/A N/A None. slowed psychomotor activity. rapid heartbeat. dry mouth. they are cheap and legal (hence. available). slowed heartbeat. sleeplessness. poor judgment. abnormally acute hearing. anger. alertness. 2+ of: red euphoria. seizures 2+ of: dysphoria. stimulation.2 impaired judgment. muscle fasciculations. tension. sweating. poor judgment. rise or fall in blood pressure or heart rate. coma. sleeplessness. N/A 143 Alcohol. excitement. improved mood and concentration. rapid pulse. upon taking an agonist) ‡ The symptoms cause clinically important distress or impair social.or slowed *Officially. brightened mood Behavioral/emotional sx during intoxication* Inappropriate sexuality or aggression. nausea. tremor. belligerence. poor judgment. impulsiveness. loss of inhibitions. trouble concentrating. poor concentration Neither Caffeine Inhalants Giddiness. hallucinations. poor job or social functioning Clinically important distress or impaired job. job. an illusion of strength. nystagmus. Legally available everywhere. impaired job or social functioning Constricted pupils (or dilated if severe overdose) plus 1+ of: sleepiness or coma. in many different forms Mild euphoria. depression. restlessness. labile mood. stupor or coma Withdrawal symptoms*†‡ 2+ of: sweating. red face. later. stereotyped behaviors. or social functioning 5+ of: restlessness. irritability. fever. for opioids. rapid or irregular heartbeat. activity level up or down. tireless periods. chills. which appeals to children Relaxed sense of well-being. muscle weakness. trouble speaking. persecutory ideas. anxiety. irregular heartbeat. rambling speech. agitation. some claim improved sexual performance. weakness. loss of concentration. lethargy. hypnotics sedatives/ anxiolytics Depend/ Abuse Depend/ Abuse Amphetamines. blurred vision. relief of withdrawal symptoms 2+ of: dizziness. indifference to pain Opioids Euphoria leading to apathy. increased talkativeness and sociability. social acceptance. some inject or inhale cocaine for sudden rush of intense pleasure Reduced fatigue and drowsiness. insomnia. dilated pupils or sweating or piloerection. excessive sleepiness or insomnia. † Noted upon cessation or reduction of heavy or prolonged use (or. weight loss. euphoria Motor deficits. trouble walking. gi upset. sensory distortions Euphoria. social withdrawal. anxiety. Depend/ nausea. irregular heartbeat Depend/ Abuse Hallucinogens Depression or anxiety. chest pain. impaired school. cocaine Elevated mood. impaired job or social functioning 2+ of: nystagmus. depressed breathing. “disconnectedness” PCP Assaultiveness. ideas of reference. fears of insanity. slurred speech. nausea or vomiting. brief hallucinations. anger. nystagmus. tremors. reduced concern for the present. numbness. poor judgment. stupor or coma. vomiting. extreme vigilance. slurred speech. or other functioning 2+ of: dilated pupils. eyes. anxiety. sweating. increased appetite or weight 3+ of: dysphoria. impaired judgment. improved sociability. increased appetite. Symptoms of substance intoxication and withdrawal and presence of dependence and abuse Substance The attraction Reduced inhibitions (including sexual). self-confidence.

school. one or after use. eg: Assaultiveness Belligerence Impulsiveness Speeded psychomotor activity Unpredictability Impaired judgment Impaired job. 2+ of: perceptual changes Dizziness •During or shortly Nystagmus after use. eg: Apathy Assaultiveness Belligerence Impaired judgment Impaired job. if severe overdose) •During or shortly after use. or social functioning Opioids •Recent use •Some required. social. or coma With perceptual disturbances •During or shortly •During or shortly after after use. chest pain. eg: Motor performance deficits Anxiety Euphoria Impaired judgment Social withdrawal Slowed sense of time Cocaine/amphetamines •Recent use •Some required. depressed breathing. or other functioning Cannabis •Recent use •Some required. eg: Inappropriate sexuality or aggression Labile mood Impaired judgment Impaired job. None With perceptual disturbances •During or shortly after use. school. 2+ of: Lack of coordination Dilated pupils Slurred speech Rapid heart rate Unsteady walking Sweating Lethargy Palpitations Slowed reflexes Blurred vision Slowed psychomotor Tremors activity Lack of Tremors coordination Muscle weakness Blurred or double vision Stupor or coma Euphoria •Within 1 hour of use. or social functioning Hallucinogens •Recent use •Some required. eg: Euphoria or blunted affect Hypervigilance Interpersonal sensitivity Anger. Criteria for intoxication with psychoactive substances Alcohol/sedatives.Substance Misuse Tables Table 2. 2+ of: Speeded or slowed heart rate Dilated pupils Blood pressure ↑ or ↓ Chills or sweating Nausea or vomiting Weight loss Speeded or slowed psychomotor activity Muscle weakness. or social functioning •During or shortly after use. use. etc. school. school. distorted voluntary movements or muscle tone. school. confusion. school. 2+ of: Red eyes Appetite ↑ Dry mouth Rapid heart rate None With With perceptual perceptual disturbances disturbances •The symptoms are neither caused by a general medical condition nor are they better explained by another mental disorder. school. or social functioning Inhalants •Recent use or exposure •Some required. then apathy Depression or anxiety Speeded or slowed psychomotor activity Impaired judgment Impaired job. or irregular heartbeat Seizures. 2+ of: Nystagmus Heightened blood pressure or heart rate Numbness or decreased pain response Trouble walking Trouble speaking Rigid muscles Coma or seizures Abnormally acute hearing None None . or social functioning 144 Maladaptive psychological/ behavioral changes Other Other symptoms specifiers •During or shortly •During or shortly after use. or tension Changes in sociability Stereotyped behaviors Impaired judgment Impaired job. 5+ of: more: Restlessness Slurred speech Nervousness Lack of Excitement coordination Sleeplessness Unsteady walking Red face Nystagmus Urination ↑ Impaired Gastrointestinal attention or upset memory Twitching muscles Stupor or coma Rambling speech Rapid or irregular heart rate Tireless periods Psychomotor activity ↑ •Within 2 hours of use. •Recent use •Some required. eg: Euphoria. 1+ of: Sleepiness or coma Slurred speech Impaired memory or attention PCP •Recent use •Some required. anxiety. pupils constricted (or dilated. or social functioning Caffeine •Recent use >250 mg •Clinically important distress or impaired job. eg: Depression or anxiety Ideas of reference Fears of insanity Persecutory ideas Impaired judgment Impaired job.

•The symptoms are neither caused by a general medical condition nor are they better explained by another mental disorder. job. perceptions of objects as larger or smaller than they actually are. With perceptual — — — — disturbances Note. &c •Heavy/prolonged use before cessation or reduction Cocaine/ amphetamines •Heavy/prolonged use before cessation or reduction Hallucinogens [See table footnote] Nicotine •Daily use for several weeks before cessation/ reduction Opioids Use Specific Symptoms General criteria Other •Several weeks of heavy use before cessation/ reduction. erect activity slowed rate hairs. 4+ of: minutes to a Sweating or rapid dysphoric mood Dysphoria or few days. 2+ of: a few days. Nausea or Sleeplessness Vivid bad frustration. . It consists in the reexperiencing of at least one of the symptoms of perception that occurred during hallucinogen intoxication (such as flashes of color. 3+ heartbeat plus two or depression of Trembling of more: Sleeplessness Dysphoria hands Fatigue Anger. hallucinogen persisting perception disorder (flashbacks) isn’t actually a disorder of withdrawal. The criteria listed as "Other" in the table body also apply to this disorder. Although it occurs after a person has ceased use of LSD or another hallucinogen. or use before using an antagonist •Within hours to a •Within hours to •Within 24 •Within few days. or other functioning. Criteria for substance withdrawal Alcohol/sedatives. halos.Substance Misuse Tables 145 Table 3. and false peripheral perception of movement). or vomiting Nausea or dreams irritability Aching vomiting Brief Increased or Anxiety muscles hallucinations or decreased sleep Trouble Tearing or illusions Heightened concentrating runny nose Speeded appetite Restlessness Dilated psychomotor Speeded or Slowed heart pupils. hours. or Grand mal seizures psychomotor Increase in sweating Anxiety activity appetite or Diarrhea weight Yawning Fever Sleeplessness •The symptoms cause clinically important distress or impair social. afterimages. trails of images. geometric hallucinations.

with impaired arousal. anxiolytics Other/unknown 146 Inclusions. or lab data shows that substance History. anxiolytics (I & W) Other/unknown (I & W) Alcohol Sedatives. for persisting amnestic disorder. activities. executive (2) elevated. previously nearly all attention explains these impaired learned). if appropriate ? Substance With Onset During Intoxication or During Withdrawal Code: With delusions. hypnotics. dementia). and each shows a decline interpersonal problems in level of functioning Also code substance dependence. Symptoms cause important distress or impaired school. hypnotics. (2) 1+ can’t recall which patient has interest or warrant No other sexual information of aphasia. symptoms. PE. anxiolytics Other/unkno wn . or sustaining attention Cognitive change (deficit of language.Delirium. social. or History. Substance With Onset During Intoxication or During Withdrawal Alcohol Amphetamines Cocaine Hallucinogens Inhalants Opioids PCP Sedatives. functioning irritable. Hypersomn ia. a month of substance use typical effects of intoxication. with impaired orgasm. hypnotics. Specify Intoxication or Withdrawal delirium Substance(s) involved Applies to: Alcohol (I & W) Amphetamines (I) Cannabis (I) Cocaine (I) Hallucinogens (I) Inhalants (I) Opioids (I) PCP (I) Sedatives. or Mixed type Based upon main features: With impaired desire. anxiolytics Other/unknown Insomnia. or that they are caused by medication use. marked distress or functioning. hypnotics. or personal functioning. or lab data suggests either that symptoms developed within 1 month of substance intoxication use fully explains the lab data or withdrawal. exclusions. anxiolytics Other/unknown With depressive manic or mixed features. or lab data suggests symptoms developed 1) during substance intoxication or were caused by medication use (for intoxication delirium) or 2) shortly after substance withdrawal (for withdrawal delirium) Persisting Persisting Dementia Psychotic Disorder Mood Disorder Anxiety Disorder Sleep Sexual Dysfunctioning Disorder Amnestic Disord Deficits of Persistence of Clinically important Impaired Prominent Prominent anxiety. or panic serious information or (1) impaired (except those for decreased attacks enough to picture. hypnotics. problem sexual dysfunctioning shown by both: mood or notably dominates the clinical learn new hallucinations obsessions. obsessive-compulsive symptoms. anxiolytics Other/unknown Alcohol Amphetamin es Caffeine Cocaine Opioids Sedatives.Substance Misuse Tables Table 4. perception) that dementia can’t better explain Sx develop rapidly (hours to days) and tend to fluctuate during the day Main symptoms History. and/or symptoms. PE. memory. hypnotics. as memory (can’t delusions or (1): Depressed compulsions. panic attacks. insight) pleasure in clinical dysfunction better apraxia. onset Intoxication der or Withdrawal (I or W) Reduced level of consciousness and difficulty focusing. shifting. Criteria for substance-related mental disorders Disor. non-substance-induced [psychotic] [mood] [anxiety] [sleep] disorder Symptoms start within effects of longer than doesn't better account for symptoms. PE. or expansive mood Symptoms don't occur solely in the context of delirium (or. either 1) suggests lasting The effects last Another. agnosia. with sexual pain. History. Also whether: With onset during intoxication Alcohol Amphetamines Cocaine PCP Sedatives. anxiolytics Other/unknown With generalized anxiety. A sleep thinking. PE. Parasomnia . hypnotics. hypnotics. orientation. or 2) have probably substance medication use causes caused the intoxication or them symptoms withdrawal Each symptom causes clinically Symptoms cause clinically important distress or impair work. with hallucinations Alcohol Amphetamines Cannabis Cocaine Hallucinogens Inhalants Opioids PCP Sedatives. or phobic symptoms Substance With Onset During Intoxication or During Withdrawal Alcohol Amphetamines Caffeine Cannabis Cocaine Hallucinogens Inhalants PCP Sedatives. anxiolytics Other/unknown Alcohol Inhalants Sedatives. memory.

drinking also took up a lot of the time he should have been studying pharmacology—he failed it outright.0 (5. What would you say Jerrald’s diagnosis was. there are a number of issues you can/should address.5 (70. 5+ days/month) Lifetime use in millions (%) 157. Just like the president. once skidding on a mountain road. 3. In college.6%)* 10. but you care more for Jim Beam than you do for me.4%) 0.4 (34.4%) 0.2%) 86.5 (5.Substance Misuse Tables Table 5 Use in millions Substance Tobacco Alcohol Marijuana and hashish Cocaine and crack Tranquilizers Hallucinogens and PCP Stimulants Inhalants Sedatives Heroin Any illicit drug *Heavy alcohol users (5+ drinks/day.” he told his roommate morosely.4 (29. he found that he stayed “sober enough to drive” even when he had drunk a 6-pack of beer in as little as an hour. when the chips were really down—as for the SATs. What are the ones that make them attractive to users? [p *] 6.8 (1.8%) 1. He’d had a couple of close calls when driving.) [p *] 5.1%) 0.7%) 14. and was told he’d have to repeat his sophomore year.8 (80.17 (0.2 (0.” The second year of medical school.5%) 1. what would you suggest to help Jerrald with his substance problem? (Hint: it’s biopsychosocial.1%) 14. when I was in funds.79 (0.2%) 13.4%) 0.62 (0. But he kept a tight lid on how often he drank—no more than once or twice a month”—because he knew he had to make the grades to get into medical school. now and then. In working with the family of any substance user. as described in high school? [p *] And in college? How would you describe his relationship with substances then? [p *] Finally.3%) 147 Review While he was still in high school.3%) 25.” And a couple of times.0%) 76.7 (7. “You know.6 (6. used to say. Several features of substance intoxication are common to nearly all the drugs listed above. inches from an unguarded plunge into a canyon.9 (38. his studying dropped pretty close to zero.5%) 180. after he’d gotten the acceptance letter to medical school. The last half of his senior year. Jerrald’s drinking was already getting out of hand.8%) 26.0 (6.3%) 0. [p *] . “I’ll drink with him.98 (0. which he aced—he managed to keep his drinking from getting out of hand. but I won’t ride with him.9%) Previous month in millions (%) 65.1 (11.13 (0.2%) 2.” she had complained more than once. 2. Name some of them.1 (3. his girlfriend moved out (“I’ve begged you to stop. he sometimes found that he’d gone through all the crack he’d been saving for a big party. 4.4 (11. he hadn’t even shown up for an important exam in calculus—and he planned to major in math when he hit college.6%) 16. His best friend. Nonetheless. more than once I’ve tried to cut down. He escaped from high school as a covaledictorian of his 550-student high school class.0 (0. “I did do a little blow. “I was pretty busy trying to score some weed.5%) 7. diagnosis in medical school? [p *] If he were your classmate.3%) 12.7 (4. “Remember when I went cold turkey before the biochem final and got the shakes?” 1. coming to rest backwards on the highway.) Apparently.” However. Ben.

leads to death of Little Nell.Substance Misuse Tables 7. pathological gambler. Discuss Jerrald’s prognosis for a full recovery from [whatever is correct diagnosis might be]. The grandfather is a classic. [p *] 148 Further Learning No one does it better than a couple of oldies Days of Wine and Roses Movie: Barfly (the challenge is not to read this as an adverb signifying emesis) More Further Learning Dickens’ Old Curiosity Shop. .

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