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

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

R)PP*RT

ni%e pro+le/s and refine their skills in esta+lishin. strate. the roles of e/pathic listener e.linde *th/er defined the develop/ent of rapport as enco/passin. patients and intervie0ers at ease< 479 findin.ht and +eco/in. a.thority as physicians and therapists< and 4(9 +alancin.pert and a.pressin.thority.ttin. rapport they developed a checklist 4Ta+le !-!9 that ena+les intervie0ers to reco. co/passion< 4'9 eval. an ally< 4&9 sho0in.)s part of a strate.atin.pertise< 4=9 esta+lishin.( STR)T#:$#S R)PP*RT  #kkehard *th/er and Sie. si. patients' pain and e. patients' insi.y for increasin. rapport- . e.ies: 4!9 p.

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

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

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

estionin.enerally do/inates the intervie0- .pected to co/ply 0itho.tocratic /odel the physician asks /ost of the 2.t 2.3odels of $nteraction Bet0een Doctor and Patient  "he paternalistic )odel.@e or she 0ill prescri+e treat/ent and the patient is e.3oreover the doctor /ay decide to 0ithhold infor/ation 0hen it is +elieved to +e in the patient's +est interests$n this /odel also called the a.$n a paternalistic relationship +et0een the doctor and patient it is ass./ed that the doctor kno0s +est..estions and .

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

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

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

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

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

the patient's perspective  Deter/inin. infor/ation and reco//endin.nicatin.tic relationship /+0ectives The patient's 0illin.re of the pro+le/  Co//. the nat. to co//on patient concerns over e/+arrass/ent sha/e and h.ine interest e/pathy s./iliation  #licitin.nderstandin.otiation  Patient satisfaction  Physician satisfaction SK!11S Definin. +earin.pression of painf. and toleratin.nction .pport and co..(nctions Developin.  )ttendin. the patient to tell his or her story  @earin.nitive . the patient's e. and /aintainin.nostic infor/ation  Relief of physical and psycholo.ical distress  Billin. treat/ent 4f.7.ness to accept a treat/ent plan or a process of ne. the nat.l feelin.en.ness to provide dia. a therape.s  )ppropriate and .re of the relationship  )llo0in.

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

ression $solation Dependency )n.er )cceptance       .iety Depression Bar.e loss Threat to ho/eostasis fear 1ail. and +la/in.re of 4self9 care helplessness hopelessness Sense of loss of control sha/e 4..ilt9  )n.iety or depression Denial or an.Predicta+le Reactions to $llness Clinical $ntrapsychic  Do0ered self i/a. Re.ainin.

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

r+a+ility The a+ility to /aintain e.nli/ited a+ility to hear pain or trial cal/ly Charity to0ard othersTo +e .ht thin. sit.stration The capacity to re/ain fir/ and deal 0ith insec. Clear A.ation so that one can say or do the ri.   .re fr.tre/e cal/ and steadiness Presence of /ind Selfcontrol in an e/er.Character and F.d.ency or e/+arrassin.s and helpf.fferin./ent The a+ility to /ake an  )+ility to end.l especially to0ard the needy and s.enero.alities of the Physician $/pert.rity and dissatisfaction $nfinite patienceThe .

te tr.ence #2.ations 0ith an .rs. standards and ideals and livin.r+ed even te/per     .ndist.ate facts and p.ed  $dealis/ 1or/in. and appearance Bravery The capacity to face or end. val.Character and F.th To investi.ani/ity The a+ility to handle stressf.e Tenacity To +e persistent in attainin.oal or adherin. to so/ethin.e reality Co/pos. .nder their infl.re Cal/ness of /ind +earin.re events 0ith co.l sit. a .alities of the Physician  The search for a+sol.ra.

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 Deliri./  Deliri./

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

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

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

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

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

'-Tho.,ht  1or/ 4coherence and connectedness9  Content
L $deational 4preocc.pations overval.ed ideas del.sions9 L Percept.al 4hall.cinations9

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

?.d,/ent

(- Co,nition  3e/ory

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

         

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

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

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

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

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

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

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

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

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

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

De/entia

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

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

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

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

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

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

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

or the na)es of fa)iliar people* . the individ(al has diffic(lty in re4isterin4. "he de4ree of )e)ory loss represents a serio(s handicap to independent livin4* /nly hi4hly learned or very fa)iliar )aterial is retained* . altho(4h. and recallin4 ele)ents involved in daily livin4 s(ch as 5here +elon4in4s have +een p(t. tho(4h not so severe as to +e inco)pati+le 5ith independent livin4* "he )ain f(nction affected is the learin4 of ne5 )aterial* . 5hat they have recently +een doin4.e5 infor)ation is retained only occasionally and very +riefly* !ndivid(als are (na+le to recall +asic infor)ation a+o(t their o5n local 4eo4raphy. or infor)ation recently i)parted +y fa)ily )e)+ers*  Moderate.10 ia4nostic Criteria fo: e)entia :!. sho(ld +e assessed as follo5s:  Mild. in )ore severe cases. s(pple)ented. the recall of previo(sly learned infor)ation )ay also +e affected* "he i)pair)ent applies to +oth ver+al and nonver+al )aterial* "he decline sho(ld +e o+0ectively verified +y o+tainin4 a relia+le history fro) an infor)ant. "he de4ree of )e)ory loss is s(fficient to interfere 5ith everyday activities. 5hich is )ost evident in the learnin4 of ne5 infor)ation. 5ith )ild i)pair)ent as the threshold for dia4nosis.or e<a)ple."here is evidence of each of the follo5in4:  ' decline in )e)ory. social arran4e)ents. +y ne(ropsycholo4ical tests or 8(antified co4nitive assess)ents* "he severity of the decline.!C . if possi+le. storin4.

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

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

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

atte/pts and car+on /ono./a 4closed and penetratin.se disorders KKK>e.ltiple sclerosis S.ia 4incl.lsive therapy KKK3.res on the +rain KKK#ncephalitis d.ical proced.res KKK@ead tra.r.nter preparations .ses KKK)lcohol .lo+al a/nesia KKK#lectroconv. KKK@ypo.9 KKKTransient ./ors 4especially thala/ic and te/poral lo+e9 KKKCere+rovasc.roto.in.lyce/ia Pri/ary +rain conditions KKKSei%.e to herpes si/ple.9 KKKCere+ral t.lar diseases 4especially thala/ic and te/poral lo+e9 KKKS.9a0or Ca(ses of ')nestic isorders  Syste/ic /edical conditions KKKThia/ine deficiency 4Korsakoff's syndro/e9 @ypo.din. nonfatal han.ide poisonin.+stance-related ca.ins KKKBen%odia%epines 4and other sedative-hypnotics9 KKK3any over-the-co.

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

Depression and Bipolar Disorder .

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

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

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

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

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

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

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

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

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

at least ! 0eek 4or any d.re to keep .rin.nificant de.!3.r+ance three 4or /ore9 of the follo0in. sy/pto/s have persisted 4fo.pansive or irrita+le /ood lastin..ration if hospitali%ation is necessary9 D.s.ree:  L inflated self-estee/ or .r if the /ood is only irrita+le9 and have +een present to a si.": Criteria for 9anic Episode  ) distinct period of a+nor/ally and persistently elevated e.al or press.feels rested after only ' ho.randiosity L decreased need for sleep 4e-.rs of sleep9 L /ore talkative than . the period of /ood dist.S9.

yin.al social activities or relationships 0ith others or to necessitate hospitali%ation to prevent har/ .s.in. L distracti+ility 4i-e..L fli.+Aective e.ally9 or psycho/otor a.ht of ideas or s.l conse2.ternal sti/.cessive involve/ent in pleas.itation L e.ni/portant or irrelevant e. in .ences 4e-.en.nctionin. or in .oal-directed activity 4either socially at 0ork or school or se.r+ance is s...hts are racin.li9 L increase in .siness invest/ents9   The sy/pto/s do not /eet criteria for a /i.fficiently severe to ca.nrestrained +.attention too easily dra0n to .ra+le activities that have a hi.h potential for painf.a.pational f.se /arked i/pair/ent in occ. sprees se.al indiscretions or foolish +..perience that tho.ed episodeThe /ood dist.

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

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

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

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

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

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

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

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

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

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

thors: Sadock BenAa/in ?a/es< Sadock Jir.inia )lcott Title: Kaplan & Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry !"th #dition issociative isorders :es()e +y dr li#a .).

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

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

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

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

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

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

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

  /rdinary for4etf(lness @@@'4e.onpatholo4ical for)s of a)nesia @@@!nfantile and childhood a)nesia @@@')nesia for sleep and drea)in4 @@@>ypnotic a)nesia e)entia eliri() ')nestic disorders .+lockers @@@1ithi() car+onate @@@9any others /ther dissociative disorders @@@ issociative f(4(e @@@ issociative identity disorder @@@ issociative disorder not other5ise specified 'c(te stress disorder Posttra()atic stress disorder So)ati#ation disorder Psychotic episode @@@1ack of )e)ory for psychotic episode 5hen ret(rns to nonpsychotic state 9ood disorder episode @@@1ack of )e)ory for aspects of episode of )ania 5hen depressed and vice versa or 5hen .related co4nitive decline .related a)nesia @@@'lcohol @@@Sedative.hypnotics @@@'nticholiner4ic a4ents @@@Steroids @@@9ari0(ana @@@.e(rolo4ical disorders 5ith discrete )e)ory loss episodes @@@Posttra()atic a)nesia @@@"ransient 4lo+al a)nesia @@@')nesia related to sei#(re disorders S(+stance.arcotic anal4esics @@@Psychedelics @@@Phencyclidine @@@9ethyldopa 6'ldo)et7 ifferential ia4nosis of issociative ')nesia  K>ypo4lyce)ic a4ents @@@AB.

Dysthy/ia and Cyclothy/ia .

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

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

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

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

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

.pation) /aAor defense /echanis/ .ht that the conflicts of depression center on oraland anal-sadistic traits.Psychosocial 1actors Psychodyna/ic theories a+o.ilt and concern for others< they are post. ad.l/inates  in diffic.cessive orderliness .lated to +e a defense a.lty adaptin. to adolescence and yo..ainst preocc.Karl )+raha/ for e.ani%ation hostility and self-preocc.lthood.n.sed is reaction for/ation.Do0 self-estee/ anhedonia and introversion are often associated 0ith the depressive character .pation 0ith anal /atter and 0ith disor.o develop/ent and c.)nal traits incl.lts fro/ personality and e.de e.t the develop/ent of dysthy/ic disorder posit that the disorder res.a/ple tho.

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

y and anhedonia that are characteristically 0orse in the /ornin.tn. clinically often fl.t of a /aAor depression the core DS3-$J-TR criteria for dysthy/ic disorder tend to e/phasi%e ve.res in dysthy/ic disorderThe profile of dysthy/ic disorder overlaps 0ith that of /aAor depressive disorder +.eno.e 7!9 or late 4a.ns 4/ore s.t differs fro/ it in that sy/pto/s tend to o.To /eet the dia.etative dysf.ate in and o.se patients presentin.ld never have had a /anic or hypo/anic episode.ated sy/pto/atolo.nitive sy/pto/s- .nction 0hereas the alternative Criterion B for dysthy/ic disorder 4Ta+le !=-7-79 in a DS3-$J-TR appendi.nted for as /aAor depressive disorder and sho.s feat.This /eans that dist.+tle endo.+Aective than o+Aective depression9.DS3-$J-TR also allo0s specification of atypical atypica feat.ncharacteristic and psycho/otor a.r+ances in appetite and li+ido are .nostic criteria a patient sho.res are o+served ho0ever: inertia lethar. lists co..This all translates into a depression 0ith atten.e 7! or older9./+er si.itation or retardation is not o+served.ld not have sy/pto/s that are +etter acco.yS.ia4nosis and Clinical .late the presence of a depressed /ood /ost of the ti/e for at least 7 years 4or ! year for children and adolescents9.DS3-$J-TR allo0s clinicians to specify 0hether the onset 0as early 4+efore a.Beca.nosis criteria for dysthy/ic disorder 4Ta+le !=-7!9 stip.ct.eat(res   The DS3-$J-TR dia.

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

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

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

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

.re L social 0ithdra0al L chronic fati.e or tiredness L feelin.s of irrita+ility or e.": 'lternative :esearch Criterion B for ysthy)ic isorder Presence 0hile depressed of three 4or /ore9 of the follo0in.enerali%ed loss of interest or pleas.t the past L s. a+o.  S9.+Aective feelin.er L decreased activity effectiveness or prod.lty in thinkin.ctivity L diffic.s of inade2.acy L feelin. reflected +y poor concentration poor /e/ory or indecisiveness .: L lo0 self-estee/ or self-confidence or feelin.ilt +roodin.s of ..s of pessi/is/ despair or hopelessness L .cessive an.!3.

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

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

ll of plans  Jersatile 0ith +road interests  *verinvolved and /eddleso/e  Eninhi+ited and sti/.  :. a life o.ilt-prone lo0 selfestee/ and preocc.Depressive  :loo/y incapa+le of f.  Pessi/istic and .troverted and people seekin.iven to +roodin.  @i.randiose  #..l.l and e.l and .t of action  1e0 +.h ener.re  $ntroverted 0ith restricted social life  Sl.acy or fail.s ..+erant  *veropti/istic and carefree  *verconfident selfass.y level f.pied 0ith inade2.ish livin..t constant interests  Passive  Relia+le dependa+le and devoted @yperthy/ic  Cheerf.n co/plainin.red +oastf.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

So/atofor/ Disorders Kaplan & Sadock's Synopsis of Psychiatry #dit dr li%a .

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

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

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

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

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

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

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

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

irre4(lar )enses. 0oints. d(rin4 se<(al interco(rse. chest. +loatin4. or other i)portant areas of f(nctionin4* Each of the follo5in4 criteria )(st have +een )et. a+do)en.": ia4nostic Criteria for So)ati#ation isorder   ' history of )any physical co)plaints +e4innin4 +efore a4e %0 years that occ(r over a period of several years and res(lt in treat)ent +ein4 so(4ht or si4nificant i)pair)ent in social. head. d(rin4 )enstr(ation. diarrhea. na(sea.!3. se<(al indifference. or intolerance of several different foods7 L one se<(al sy)pto): a history of at least one se<(al or reprod(ctive sy)pto) other than pain 6e*4*. 5ith individ(al sy)pto)s occ(rrin4 at any ti)e d(rin4 the co(rse of the dist(r+ance: fo(r pain sy)pto)s: a history of pain related to at least fo(r different sites or f(nctions 6e*4*. erectile or e0ac(latory dysf(nction. +ack. vo)itin4 thro(4ho(t pre4nancy7 . occ(pational. or d(rin4 (rination7 L t5o 4astrointestinal sy)pto)s: a history of at least t5o 4astrointestinal sy)pto)s other than pain 6e*4*. e<cessive )enstr(al +leedin4.S9. rect(). e<tre)ities. vo)itin4 other than d(rin4 pre4nancy.

diffic(lty s5allo5in4 or l()p in throat. the physical co)plaints or res(ltin4 social or occ(pational i)pair)ent are in e<cess of 5hat 5o(ld +e e<pected fro) the history. +lindness. a )edication7 L 5hen there is a related 4eneral )edical condition. hall(cinations. loss of to(ch or pain sensation. do(+le vision. aphonia. physical e<a)ination. paralysis or locali#ed 5eakness. a dr(4 of a+(se.L one pse(done(rolo4ical sy)pto): a history of at least one sy)pto) or deficit s(44estin4 a ne(rolo4ical condition not li)ited to pain 6conversion sy)pto)s s(ch as i)paired coordination or +alance. (rinary retention. deafness. sei#(resE dissociative sy)pto)s s(ch as a)nesiaE or loss of conscio(sness other than faintin47  Either 617 or 6-7: L after appropriate investi4ation. each of the sy)pto)s in Criterion B cannot +e f(lly e<plained +y a kno5n 4eneral )edical condition or the direct effects of a s(+stance 6e*4*. or la+oratory findin4s  "he sy)pto)s are not intentionally prod(ced or fei4ned 6as in factitio(s disorder or )alin4erin47* .

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

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

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

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

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

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

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

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

res )+nor/al .tre/ities 3idline anesthesia Blindness T. or syncope  .nnel vision Deafness 3isceral Sy)pto)s Psycho.s hysteric. Pse.ait 1allin.enic vo/itin.Conversion Disorder  Co))on Sy)pto)s of Conversion isorder 9otor Sy)pto)s $nvol. )stasia-a+asia Paralysis Beakness )phonia    Sensory eficits )nesthesia especially of e.s S0oonin.ntary /ove/ents Tics Blepharospas/ Torticollis *pisthotonos Sei%.docyesis :lo+.

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

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

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

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

lly e.lt.erin.ed to +e associated 0ith the sy/pto/ or deficit +eca. vol.nction that s. S9.s disorder or /alin.ical or other ...ned 4as in factitio.!3.ntary /otor or sensory f.9The sy/pto/ or deficit cannot after appropriate investi.d.eneral /edical conditionPsycholo.rolo.rally sanctioned +ehavior or e.est a ne.plained +y a .se the initiation or e.acer+ation of the sy/pto/ or deficit is preceded +y conflicts or other stressorsThe sy/pto/ or deficit is not intentionally prod.ced or fei.ical factors are A.perience- .": isorder ia4nostic Criteria for Conversion     *ne or /ore sy/pto/s or deficits affectin.ation +e f.+stance or as a c.eneral /edical condition or +y the direct effects of a s.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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nctional and Behavioral >e.roanato/y Sadock BenAa/in ?a/es< Sadock Jir.inia )lcott Title: Kaplan & Sadock's Synopsis of Psychiatry #D$T DR D$G) .1.

otak /en.n.si otak  neocorte.si dala/ /en.ar.r e/osi dan /e/ori e/osional  +atan.at. aliran darah ke/a/p.h antara lain deny.an ..n.si ve.1. /e/ori +ahasa  sistek li/+ic +erf. +erfikir +erhit.n.n.etasi t.r f.erak ata.+. /otorik .t Aant.

K!:! '"'S 1o4is K(antitatif Kritis 'nalitis .act(al Ko4nitif Pra4)ati k Kanan atas Konsept(al Sintesis 9etaforis 3is(al !nte4rative Chole Brained :ealistis Co))on Sense Kreatif .at(ral !dealistis Kinestetik Sek(ensial "erkontrol Konservatif Str(kt(ral 9endetail E)osional !ndria5i >()anistik 9(sical Ekspresif !nt(itif !nstin4tif Kanan +a5ah Kiri +a5ah .

)nato/i otak .

.

a.tive f...lation 4left9 *ccipital lo+es KKKJision KKKJis.nction KKK3otivation Te/poral lo+es KKK).(nctions of the >()an Brain   1rontal lo+es KKKJol. 4left9 KKKCalc.e co/prehension 4left9 KKKSensory prosody 4ri.a.ht9 KKKCo/port/ent KKK#.ht9 KKK3e/ory KKK#/otion Parietal lo+es KKKTactile sensation KKKJis.ec.ction 4left9 KKK3otor prosody 4ri.dition KKKDan.ntary /ove/ent KKKDan.al perception 4Reprinted fro/ 1illey C3Neurobehavioral Anatomy>i0ot C*: Eniversity Press of Colorado< !66=:( 0ith per/ission-9    .ospatial f.:e4ional .e prod.ht9 KKKReadin.nction 4ri.

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/atriptan =-@T( )C Tar.et of hall..raine dr.ens atypical antipsychotics =-@T7B P$ t.ens atypical antipsychotics 3onoa/ine Receptors: S#R*T*>$>  =-@T7) P$ t.cino..ression =-@T!D Tar. s.onists antie/etic an.iety sei%.cino.rnoverRe.ens antipsychotics =-@T' Cation selective $on channel)nta..rnoverRe.=-@T!) action< partial a.nitive enhance/ent =-@T )C 3od..lation of .et of anti/i..et of hall.raine dr.et of hall.iolytic =-@T!B Possi+le role in loco/otor activity a.et of anti/i.rnover )ntidepressant     Tar.lation of appetite an. s.onist< an.lation of sto/ach contraction =-@T7C P$ t.iolytic co.res< tar./atriptan =-@T!1 Tar.cino.

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

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

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

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

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

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

ptake of dopa/ine in striat.>e.her in patients 0ith schi%ophrenia than in controls@i.roche/ical 1indin.s fro/ P#T Radiotracer Scans  Dopa/ineDecreased .h dopa/ine release associated 0ith positive sy/pto/s in schi%ophrenia- ./ in parkinsonian patients Dopa/ine release is hi.

 Receptors  D!

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

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

   

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

ra/ 4##:9 )lterations )ssociated 0ith 3edication and Dr./ Slo0in.s .ys/al activity )lcohol Decreased alpha activity< increased theta activity *pioids Decreased alpha activity< increased volta.etiapine 4Sero2..enerali%ed paro.e of theta and delta 0aves< in overdose slo0 0aves Bar+it.nificant chan.el9 )ripipra%ole 4)+ilify9 >o si.es 3ariA.ana$nhalants Diff.rates$ncreased +eta activity< in 0ithdra0al states . of delta and theta 0aves >icotine $ncreased alpha activity< in 0ithdra0al /arked #lectroencephalo.a9 Risperidone 4Risperdal9 F.         Ben%odia%epines $ncreased +eta activity Clo%apine 4Clo%aril9 *lan%apine 4Gypre.ys/al activity and spike dischar.se slo0in. or paro.ana$ncreased alpha activity in frontal area of +rain< overall slo0 alpha activity CocaineSi/ilar to /ariA.es Dithi.

p to ("T9 of ##: a+nor/alities vers.#lectroencephalo.le o.es . attack in one third of patients< focal slo0in.t 7=T of patients CatatoniaEs.es consistent 0ith partial sei%.ys/al ##: chan.h prevalence 4.rin.t ##: indicated in ne0 patient presentin.ra/ 4##:9 )lterations )ssociated 0ith Psychiatric Disorders    Panic disorder Paro. in a+o. 0ith catatonia to r.t other ca.ally nor/al +.ses )ttention-deficit/hyperactivity disorder 4)D@D9@i.s nor/al controls< spike or spike-0ave dischar.re activity d.

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