Current Clinical Strategies

Psychiatry 2003-2004 Edition

Rhoda K Hahn, MD Clinical Professor
DepartmentofPsychiatryand Human Behavior
University of California, Irvine, College of
Medicine
Lawrence J. Albers, MD Assistant Clinical Professor DepartmentofPsychiatryand Human Behavior University of California, Irvine, College of Medicine Christopher Reist, MD Vice Chairman
DepartmentofPsychiatryand Human Behavior
University of California, Irvine, College of
Medicine

Current Clinical Strategies Publishing www.ccspublishing.com/ccs

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Copyright ©2003-2004 Current Clinical Strategies Publishing. All rights reserved. This book, or any parts thereof, may not be reproduced, photocopied or stored in an information retrieval network without the permission of the publisher. No warranty for errors or omissions exists, expressed or implied. Readers are advised to consult the drug package insert and other references before using any therapeutic agent. Current Clinical Strategies is a registered trademark of Current Clinical Strategies Publishing. Current Clinical Strategies Publishing 27071 Cabot Road Laguna Hills, California 92653-7011 Phone: 800-331-8227 Internet: www.ccspublishing.com/ccs E-mail: info@ccspublishing.com Printed in USA ISBN 1-929622-30-9

Assessment and Evaluation
Clinical Evaluation of the Psychiatric Patient
I. Psychiatric History A. Identifying information. Age, sex, marital status, race, referral source. B. Chief complaint (CC). Reason for consultation; the reason is usually a direct quote from the patient. C. History of present illness (HPI) 1. Current symptoms: date of onset, duration and course of symptoms. 2. Previous psychiatric symptoms and treatment. 3. Recent psychosocial stressors: stressful life events that may have contributed to the patient's current presentation. 4. Reason the patient is presenting now. 5. This section provides evidence that supports or rules out relevant diagnoses. Therefore, documenting the absence of pertinentsymptoms is also important. 6. Historical evidence in this section should be relevant to the current presentation. D. Past psychiatric history 1. Previous and current psychiatric diagnoses. 2. History of psychiatric treatment, including outpatient and inpatient treatment. 3. History of psychotropic medication use. 4. History of suicide attempts and potential lethality. E. Past medical history 1. Current and/or previous medical problems. 2. Type oftreatment,includingprescription, over-the-counter medications, home remedies. F. Family history. Relatives with history of psychiatric disorders, suicide or suicide attempts, alcohol or substance abuse. G. Social history 1. Source of income. 2. Level of education, relationship history(including marriages, sexual orientation, number of children); individuals that currently live with patient. 3. Support network. 4. Current alcohol or illicit drug usage. 5. Occupational history. H. Developmental history.Familystructure during childhood, relationships with parental figures and siblings; developmental milestones, peer relationships, school performance.

General appearance and behavior 1. Degree of eye contact. Interpreting . Grooming. Mental Status Exam.levelofhygiene. h. anxious). Flat. Poverty of speech. Clanging. C. k. Labile. angry.Moderately reduced range of affect. Ability to interact with the interviewer. euphoric. Minimal responses. Full or wide range of affect. Repetition of phrases or words in the flow of speech. Absence of all or most affect. such as rhyming and punning rather than logical connections. range and appropriateness. typical of mania. f. Accelerated thoughts that jump from idea to idea. 4. Thought that wanders from the original point. b. Illogicalshifting between unrelated topics. described in terms of quality. The tone. l. Perseveration. Ideas of reference. often in the middle of a statement. 2. D. Generally appropriate. Speech based on sound. Tangentiality. Types of affect a. d. Blocking. Echolalia. b. Attitude. Rapid speech. 2. i. j. associations and fluencyof speech should be noted. Common thought disorders a. Echoing of words and phrases. e. Unusual physical characteristics or movements. 3. d. Circumstantiality. Psychomotor activity. Bluntedorrestricted. B. Flight of ideas. Historical information should not be included in this section. Sudden cessation of speech. such as answering just “yes or no. c. The mental status exam is an assessment of the patient at the present time. Mood. which is typical of patients with manic disorder.characteristics of clothing.II. Loosening of associations. 2. which eventually reaches the point. Use of language. 5.Unnecessary digression. Thought processes 1. euthymic. g. dysphoric. Affect 1. Definition. A. Multiple abrupt changes in affect. Quality and quantity of speech. Invention of new words by the patient. Internal emotional tone of the patient (ie. Agitation or retardation. Pressured speech.External range ofexpression. Neologisms.” c.

Derealization. which may be auditory. e. Erotomanic delusions. F. H. 3. False belief that others are trying to cause harm. or wealth. place and date. Fund of knowledge: Ability to name past five presidents. or are spying with intent to cause harm. firmlyheldinspite of contradictory evidence. Fixed. power. d. Short-term memory: Ability to recall three objectsafterfive minutes. Definition. b. Delusions.delusions and other perceptual disturbances. False sensory perceptions. Persecutory delusions. c. 7. G. Hallucinations. is in love with the patient. Grandiose delusions. false beliefs. Orientation: Person. Depersonalization. Proverb interpretation and similarities. unrelated events as having direct reference to the patient. or historical dates. False belief of an inflated sense of self-worth. Ability to make sound . Common thought content disorders a. gustatory or olfactory. knowledge. Feelings of unrealness involving the outer environment. Ability of the patient to display an understandingofhiscurrentproblems. Insight. Misinterpretations of reality. Thought content 1. i. Cognitive evaluation 1. iii. 4. such as believing thatthe television is talking specifically to them.tactile. Judgment. usually of higher status. 2. five large cities. Attention and concentration: Repeat five digits forwards and backwards or spell a five-letter word(“world”) forwards and backwards. Level of consciousness. visual. False belief that a person. 5. f. simple math problems. Somatic delusions. Hallucinations. Illusions. such as if one is “outside” of the body and observing his own activities. Abstraction.E. False belief that the patient has aphysical disorder or defect. Feelings of unrealness. 2. Suicidal and homicidal ideation requires further elaboration with comments about intent and planning (including means to carry out plan). Subtraction of serial 7s. iv. Calculations. Suicidaland homicidal ideation. and the ability to understand the implication of these problems. 6. ii.

DSM-IVMultiaxialAssessment Diagnosis Axis I: Clinical disorders Other conditions that may be a focus of clinical attention. V. A thorough physical and neurological examination. Axis II: Personality disorders Mental retardation Axis III: General medical conditions Axis IV: Psychosocial and environmental problems Axis V: Global assessment of functioning IV. Labs: Chem 20. CBC with differential. Treatment Plan. Diet: Regular diet. A. Screening test for syphilis (RPR or MHA-TP). Precautions: Assault or suicide precautions.ratherthan byasking hypothetical questions. B. UA with toxicology screen. Blood chemistry (SMAC). thyroid function. 5. such as Tylenol. serum levels of medications. General Medical Screening of the Psychiatric Patient. Medications: As indicated by the patient’s diagnosis or target symptoms. Activity: Restrict to the unit or allow patient to leave unit. 6. Admitting Orders Admit to: (name of unit) Diagnosis: DSM-IV diagnosis justifying the admit. 4. Condition: Stable. soft mechanical. then q day if stable. 9. 2. including basic screening laboratory studies to rule out physical conditions. Thyroid function panel. 7. Allergies: No known allergies. Urinalysis with drug screen. Vitals: Standard orders are q shift x 3. III. Serum levels of medications. Urine pregnancycheck for females of child bearing potential. . CBC with diff. Legal Status: Voluntary or involuntary status-if involuntary. Blood alcohol level. elopement precautions. should be completed. This section should discuss pharmacologic treatment and otherpsychiatric therapy. Laboratoryevaluationof the psychiatric patient 1.decisions regarding everydayactivities. HIV test in high-risk patients. Include as needed medications. state specific status. RPR. ADA diet. urine pregnancy test. Judgement is best evaluated by assessing a patient's historyof decision making.including hospitalization. 3. if there are medical concerns. Amore extensive workup and laboratory studies may be indicated based on clinical findings. 8. vitals should be ordered more frequently.

Acute Exacerbation. CBC with diff. 5150 in California). Zaleplon (Sonata) 10 mg po qhs prn insomnia. Medications: Olanzapine (Zyprexa) 10 mg po qhs. Diagnosis: Schizophrenia. CBC with diff. Medications: Risperidone (Risperdal) 2 mg po bid x 2 days. Schizophrenia Admitting Orders Admit to: Acute Psychiatric Unit. Allergies: No known allergies. RPR. Vitals: q shift x 3. Vitals: q shift x 3. Labs: Chem 20. Mylanta 30 cc po q 4 hours prn dyspepsia. Legal Status: Involuntary by conservator. thyroid function. Precautions: Elopement precautions. Condition: Actively Psychotic. Manic with psychotic features. urine pregnancy test. Precautions: Assault precautions. Depakote 500 mg po tid. thyroid function. Zolpidem (Ambien) 10 mg po qhs prn insomnia. Lorazepam (Ativan) 2 mg po q 4 hours prn agitation (not to exceed 8 mg/24 hours. then q day if stable. Diet: Regular. antacids. UA with toxicology screen. urine pregnancy test. Mylanta 30 cc po q 4 hours prn dyspepsia. Lorazepam (Ativan) 2 mg po q 4 hours prn agitation (not to exceed 8 mg/24 hours. UA with toxicology screen. Milk of magnesia 30 cc po q 12 hours prn constipation. Allergies: No known allergies.milk of magnesia. Milk of magnesia 30 cc po q 12 hours prn constipation. . then 4 mg po qhs. Activity: Restrict to unit. Diet: Regular. Labs: Chem 20. Continuous Paranoid Type. Activity: Restrict to unit. RPR. Tylenol 650 mg po q 4 hours prn pain or fever. Condition: Actively Psychotic. then q day if stable. Legal Status: Involuntary (legal hold. Bipolar I Disorder Admitting Orders Admit to: Acute Psychiatric Unit. valproate level. Diagnosis: Bipolar I Disorder. Tylenol 650 mg po q 4 hours prn pain or fever.

Labs: Chem 20. Precautions: Suicide precautions. RPR. diastolic BP >100 [not to exceed 14 mg/24 hour]). Activity: Restrict to unit. Milk of magnesia 30 cc po q 12 hours prn constipation. Condition: Guarded. thyroid function. Zolpidem (Ambien) 10 mg po qhs prn insomnia. CBC with diff. thyroid function. Diet: Regular. Tylenol 650 mg po q 4 hours prn pain or fever. Thiamine 100 mg IM qd x 3 days. Lorazepam (Ativan) 2 mg po tid x 2 days. Vitals: q shift x 3 days. RPR. Medications: Sertraline (Zoloft) 50 mg po qAM. Activity: Restrict to unit. then q day if stable. Lorazepam (Ativan) 2 mg po q 4 hours prn alcohol withdrawal symptoms (pulse >100. . CBC with diff. then discontinue. systolic BP >160. without psychotic features.Major Depression Admitting Orders Admit to: Acute Psychiatric Unit. UA with toxicology screen. Alcohol DependenceAdmitting Orders Admit to: Alcohol Treatment Unit. Labs: Chem 20. Allergies: No known allergies. Multivitamin 1 po qd. Legal Status: Voluntary. Condition: Stable. severe. then 100 mg po qd. Mylanta 30 cc po q 4 hours prn dyspepsia. urine pregnancy test. UA with toxicology screen. then q day if stable. Medications: Folate 1 mg po qd. urine pregnancy test. Trazodone (Desyrel) 100 mg po qhs prn insomnia. Allergies: No known allergies. Lorazepam (Ativan) 2 mg po q 4 hours prn agitation (not to exceed 8 mg/24 hours. Vitals: q shift x 3. then 2 mg bid x 2 days. Tylenol 650 mg po q 4 hours prn pain or fever. then 1 mg po bid x 2 days. Diagnosis: Major Depression. Milk of magnesia 30 cc po q 12 hours prn constipation. Diagnosis: Alcohol Dependence. Diet: Regular with one can of Ensure with each meal. Precautions:Seizure and withdrawal precautions. Legal Status: Voluntary.

OpiateDependenceAdmitting Orders Admit to: Acute Psychiatric Unit. then q day if stable. Schizoaffective Disorder Admitting Orders Admit to: Acute Psychiatric Unit. hold for systolic BP <90 or diastolic BP <60). Diagnosis: Schizoaffective disorder. thyroid function. Mylanta 30 cc po q 4 hours prn dyspepsia. Medications: Quetiapine (Seroquel) 100 mg po bid x 2 days. Vitals: q shift x 3 days. HIV. Diet: Regular. depressed. Dicyclomine (Bentyl) 20 mg po q 6 hours prn cramping. Tylenol 650 mg po q 4 hours prn pain . Give 0. Labs: Chem 20. hepatitis panel.Mylanta 30 cc po q 4 hours prn dyspepsia. then 200 mg po bid. Activity: Restrict to unit. CBC with diff. Lorazepam (Ativan) 2 mg po q 4 hours prn agitation (not to exceed 8 mg/24 hours). Lithium 600 mg po bid. Condition: Stable. Lorazepam (Ativan) 2 mg po q 4 hours prn agitation (not to exceed 8 mg/24 hours. Labs: Chem 20. Vitals: q shift x 3. urine pregnancy test. Diet: Regular. Legal Status: Voluntary. Precautions: Suicide precautions. urine pregnancy test. UA with toxicology screen. Allergies: No known allergies. UA with toxicology screen. Ibuprofen (Advil) 600 mg po q 6 hours prn pain/headache. lithium level. Citalopram (Celexa) 20 mg po q am. Zolpidem (Ambien) 10 mg po qhs prn insomnia. then q day if stable. CBC with diff. thyroid function.1 mg po qid. Diagnosis: Heroin dependance. bipolar type. Milk of magnesia 30 cc po q 12 hours prn constipation. Activity: Restrict to unit. Allergies: No known allergies. RPR. Condition: Stable. Methocarbamol (Robaxin) 500 mg po q 6 hours prn muscle pain. Zolpidem (Ambien) 10 mg po qhs prn insomnia.1 mg po q 4 hours prn signs and symptoms ofopiate withdrawal. RPR. Precautions: Opiate withdrawal. Medications: Clonidine (Catapres) 0. Legal Status: Voluntary.

and arrangements for discharge. Indication: Confused. Time Begin at _____o’clock. Example Restraint Note Date/time/writer: The patient became agitated and without provocation. Attempting to get our of bed. He will be given haloperidol (Haldol) 5 mg IM and lorazepam (Ativan) 2 mg IMbecause he has refused oral medication. Restraint Orders 1. Progress notes should address every element of the problem list. Agitated. Other less restrictive measures. therefore. threat to self. plans to treat those problems. Not to exceed (specify number of hours). 3. Staff may decrease or release restraints at their discretion. Mylanta 30 cc po q 4 hours prn dyspepsia. fall risk. . or dressing. 4-point leather restraint. were considered butdeemed inappropriate given his severe agitation and assaultive behavior. or soft restraints. Combative. threat to self. 5. threat to self/others. immediate 4-point restraints were required.or fever. Monitor patient as directed by hospital policy. 4. threwa chair and threatened severalpatientsverbally.Hewasunmanageable. Attempting to pull out tube. Psychiatric Progress Notes Daily progress notes should summarize the patient’s current clinical condition and should review developments in the patient's hospital course. Type of Restraint: Seclusion. Restraint Notes The restraint note should document that less restrictive measures were attempted and failed orwereconsidered. 2. line. The note should address problems that remain active.butnotappropriate for the urgent clinical situation. such as locked seclusion. Milk of magnesia 30 cc po q 12 hours prn constipation. He will be observed per protocol and may be released at staff’s discretion.

and feelings. anxious. life events. paranoid ideation. Thought Processes: Quality and quantityof speech. suicidal ideation. Information reported by the patient may include complaints.stable or activelypsychotic). concentration. abnormal involuntary movements). Objective: Discuss pertinent clinical events and observations of the nursing staff. Mood: Dysphoric. side effects. future considerations. The assessment should include reasons that support the patient’s continuing need for hospitalization. angry. full. Cognitive: Orientation. labile. attention. and issues that require continued monitoring should be discussed. symptoms. euphoric. monitoring of medication side effects (eg. Current medications:Listmedications and dosages.Documentation of dangerousness to self or others should be addressed. WBCs. Documentation may include suicidality. Affect: Flat.Aseparate assessment should be written for each problem (eg. blunted. and speech abnormalities. Plan: Changes to current treatment.Psychiatric Progress Note Date/time/writer: Subjective: A direct quote from the patient should be written in the chart. homicidality. Insight: Abilityof the patientunderstand his current problems Judgment: Decision-making ability. associations and fluency of speech. euthymic. informed consent issues. Thought Content: Hallucinations. Assessment: This section should be organized byproblem. Tone. serum drug levels. Labs: New test results. .

The patient remains actively paranoid and intermittently compliant with recom­ mended medication. The patient denies homicidal ideation. On exam. Schizophrenia. Risperdal 2 mg PO BID. Oth­ erwise the patient remains elec­ tively mute. food and fluid intake. which were offered to her. Insight: Poor. Thought Processes: Speech is limited to a few paranoid statements about the FBI.Example Inpatient Progress Note Date/time/Psychiatry R2 S: “The FBI is trying to kill me. The patient meets criteria for involuntary hospitalization due to an inability to pro­ vide food. P: 1. . The patient denies visual hallucination. Cognitive: The patient would not answer orientation ques­ tions due to paranoid ideation. Con­ tinue to encourage patient to take medication. Patient also is reluctant to eat or drink fearing that the food is poisoned. Thought Content: Auditory hallucinations and paranoid ideation. Mood: Dysphoric. but states that she would harm anyone from the FBI who tried to hurt her. Draw electrolyte panel in the AM to monitor hydration status. 3. chronic. O: The patient slept for only 2 hours last night and refused to take medications. Affect: Flat. The patient is actively psychotic and para­ noid. with extensive impact on functioning. paranoid type with acute exacerbation. the patient displayed poor eye contact. clothing and shelter for herself. Continue to monitor sleep. Judgment: Impaired. A: 1. 2. Legal Status: The patient is currently hospitalized on an involuntary basis. suicidal ideation. and psychomotor agitation. She became frightened during our interview and refused to talk after 5 min­ utes.” The patient reports that she was unable to sleep last night because the FBI harassed her by talking to her.

diagnostic tests and response to interventions are also discussed. CT scan. Disposition: Describe the situation to which the patient will be discharged (home. .consultations. Diagnostic Tests.and medical/surgical consultations and treatment. Patient'sNameand MedicalRecordNumber: Date of Admission: Date of Discharge: DSM-IV Multiaxial Discharge Diagnosis Axis I: Clinical disorders Other conditions that maybe a focus of clinical attention. mental status exam and physical examination. Invasive Procedures: History of Present Illness: Include salient features surrounding reason for admission. including psychiatric drugtherapy. and brain imaging. including evaluation. and describe the present status of the patient. social history. Discharge Medications: Follow-up Arrangements: Discharge Summary The discharge summary reviews how a patient presented to the hospital. salient psychosocial information. outcome of treatment. Discharge Note Date/time: Diagnoses: Treatment: Briefly describe therapy provided during hospitalization. Studies Performed: Electrocardiograms. nursing home). and unresolved issues at discharge. Hospital Course: Describe the course of the patient's illness while in the hospital. Axis II: Personality disorders Axis III: Medical conditions Axis IV: Psychosocial and environmental problems Axis V: Global assessment of functioning Attending or Ward Team Responsible for Patient: Surgical Procedures. past psychiatric history. psychological testing. psychological testing.Discharge Note The discharge note should be written in the patient’s chart prior to dis­ charge. Diagnostic Data: Results of laboratory testing.medications. DischargedCondition:Describe improvement or deterioration in the patient's condition. and the course of treatment. All items on the problem list should be addressed. and indicate who will take care of patient.

The patient is asked to consider pictures of people in a variety of situations. Thinking is logical and goal directed. I. A. dosages. but output is decreased. Plan: Increase nefazodone from 200 mg bid to 200 mg q AM and 400 mg qhs. sleep.Legal Status at Discharge: Voluntary. Discharge Medications: List medications. involuntary. and appetite. and judgment remains good. No psychotic symptoms are noted. Continue weekly supportive therapy. conservatorship. B. Thematic Apperception Test (TAT). exercise. The patient denies any side effects of medications other than mild nausea that has been diminishing over the past few days. Psychological Testing Psychological testing often provides additional information that complements the psychiatric history and mental status exam. Copies: Send copies to attending. clinic. Speech is more spontaneous. Assessment: Major depressionisimproving with nefazodone (Serzone) and supportive psychotherapy. Example Outpatient Progress Note Subjective: The patient reports improved mood. but energy remains low. Objective: The patient is casuallydressed with good grooming. The patient denies any recent suicidal or homicidal ideation. but the patient still has symptoms after 4 weeks of treatment at 200 mg bid. particularlyhelpful in psychodynamic formulation and assessment of defensemechanismsandegoboundaries.quantities dispensed. and interpersonal relationships. Affect is brighter but still constricted. Refer to senior center for increased social interaction. conflicts. Rorschach Test. Ink blots serve as stimuli for free associations. The patient’s spouse reports increased interest in usual activities. Discharge Instructions and Follow-up Care: Date of return for follow-up care at clinic. Cognition is grossly intact. as well asdescribe personalityandmotivations.and instructions. fantasies. Mood remains depressed but improved from the previous visit. consultants. . Psychological tests characterize psychological symptoms. and is asked to make up a story for each card. Insight is improving. defenses. This test provides information about needs. diet.

Results are given in 10 scales. . and then to draw a picture of a person of the opposite sex of the first drawing. References References. Halstead-ReitanBatteryandLuria-Nebraska Inventory 1. Sentence Completion Test (SCT). Intelligence test that measures verbal IQ. Draw-a-Person Test (DAP). D.visual-motor function. Patients are asked tofinish incomplete sentences. Assess expressive and receptive language. useful for children and adults. BenderGestalt Test. Wisconsin Card Sort. 2. and full-scale IQ. Minnesota Multiphasic Personality Inventory (MMPI). fears and preoccupations of the patient. Provides insight into defenses. II.A test ofvisual-motor and spatial abilities. A battery of questions assessing personality characteristics.C.sensory-perceptual function and motor function. Neuropsychological tests assess cognitive abilities and can assist in characterizing impaired brain function. The drawings represent how the patient relates to his environment. C. A. therebyrevealing conscious associations. Standardized evaluation of brain functioning. B. see page 121. A test of frontal lobe function. D. The patient is asked to draw a picture of a person. Wechsler Adult Intelligence Scale (WAIS). intellectual reasoning and judgment. and the test may also be used as a screening exam for brain damage.performance IQ. E. memory.

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and affective blunting. incoherentthoughts. . A prior history of schizotypal or schizoid personality traits or disorder is often present. Depression and neurocognitive dysfunction are gaining acceptance astermsto describe twoothercoresymptoms ofschizophrenia. 2. Delusions. Disorganized behavior. c. Positive symptoms a.and ideas of reference. Disorganized speech. DSM-IV Diagnostic Criteria for Schizophrenia A. Loss of motivation (avolition). Thought disorder is characterized byloose associations. I. Decline in social and/or occupational functioning since the onset of illness. d. perceptions. Delusions. c. The disturbance is not due to substance abuse or a medical condition F. hallucinations and misinterpretations of reality. alogia. d. C. 3. Poverty of speech (alogia) or poverty of thought content. Symptoms of schizophrenia have been traditionally categorized as either positive or negative. D. affective flattening. Many schizophrenics display delusions. mood.neologisms. 1. and behavior. Continuous signs of illness for at least six months with at least one month of active symptoms. Two or more of the following symptoms present for one month: 1. If historyof autistic disorder or pervasive developmental disorder is present. Schizoaffective disorder and mood disorder with psychotic features have been excluded. Grossly disorganized or catatonic behavior. Anhedonia. These patients have alterations in thoughts. 4.Psychotic Disorders Schizophrenia Schizophrenia is a disorder characterized by apathy.buthallucinations can occurinanysensorymodality.thought insertion. Hallucinations are mostcommonly auditoryor visual. Flat affect. thoughtblocking. B. E. thought broadcasting. 2. II. tangentiality. Clinical Features of Schizophrenia A. 5. absence of initiative (avolition). avolition). Hallucinations. b. b. Negative symptoms (ie. Negative symptoms a. B. schizophrenia may be diagnosed onlyifprominentdelusionsorhallucinations have been present for one month.

and the incidence of substance abuse is increased (especially alcohol. C. E.butantidepressants may be required. . but some have a gradual improvement with a decrease in positive symptoms and increased functioning. Attentional deficits. and particular types of memory) contribute to disability and can be an obstacle in long-term treatment. Males and females are equallyaffected. Paranoid type Schizophrenia 1. Paranoid type schizophrenia is characterized by the absence of prominentdisorganization ofspeech. Characterized by a preoccupation with one or more delusions or frequent auditory hallucinations. Motoric immobility. The lifetime prevalence of schizophrenia is one percent. Onset of psychosis usually occurs in the late teens or early twenties. cocaine. olfactory or gustatoryhallucinations mayindicate an organic etiology such as complex partial seizures. E. IV. B. f. Very few patients have a complete recovery. Disorganized type Schizophrenia is characterized byprominentdisorganized speech. Most patients followa chronic downward course. Catatonic type Schizophrenia is characterized by at least two of the following: 1. 2. Insight and judgment are frequently impaired. 2. No sign or symptom is pathognomonic of schizophrenia. disorganized behavior. similar to the rate that occurs in depressive illnesses. executive function.Classification of Schizophrenia A. Loss of social interest. Atypical antipsychotics often improve depressive signs and symptoms. C. Atypical antipsychotics mayimprove cognitive impairment. 4. B. D. methamphetamine and marijuana). More than 75% of patients are smokers. III. but the mean age ofonsetisapproximately six years later in females. Excessive motor activity. disorganized or catatonic behavior. D. 3. Cognitive impairment. and flat or inappropriate affect. Cognitive dysfunction (including attention. F. or flat or inappropriate affect. Epidemiology of Schizophrenia A. The presence of tactile. C. Sensorium is intact. Depression is common and often severe in schizophrenia and can compromise functional status and response to treatment. The suicide rate is 10-13%.e. Females frequently have a milder course of illness.

The criteria for schizophrenia is met. schizoid or borderline personality disorders 1. or catatonic type. Peculiar voluntary movements such as bizarre posturing. disorganized speech and grossly disorganized or catatonic behavior and continued negative symptoms or two or more attenuated positive symptoms. paranoia. multiple strokes. Echolalia or echopraxia. C. Residual type Schizophrenia is characterizedbytheabsenceofprominent delusions. A complete discussion of the treatment of Schizophrenia can be found on . Disturbances of mood are frequent in all phases of schizophrenia. C. Psychotic disorder due to a general medical condition. B.thyrotoxicosis. delirium. paranoid. B. but the duration of illness is less than six months. Included would be CNS infections. but it cannot be characterized as paranoid. In schizophrenia. F. Duration of symptoms is between one day to one month. myxedema. Psychosocial treatments in conjunction with medications are often indicated. G. Non-bizarre delusions are present in the absence of other psychotic symptoms. or dementia.3. Schizoaffective disorder. E. Schizophreniform disorder. 5. Amphetamines and cocaine frequently cause hallucinations.lupus. 2. disorganized. Antipsychotic medications reduce core symptoms and are the cornerstone of treatment of schizophrenia. Psychotic symptoms are generally mild and brief in duration. Brief psychotic disorder. hepatic encephalopathy. Mood symptoms are present for a significant portion of the illness. Schizotypal. Pharmacotherapy. VI. Patterns of behavior are life-long.Treatment of Schizophrenia A. Daytreatment programs. Delusional disorder. H. Phencyclidine (PCP) may lead to both positive and negative symptoms. Psychotic symptoms occur only during major mood disturbance (mania or major depression). E. Undifferentiated typeSchizophrenia meets criteria for schizophrenia. V. with no identifiable time of onset. HIV. D. and others. Substance-induced psychotic disorder. D. Mood disorderwith psychotic features 1. Differential Diagnosis of Schizophrenia A. 4. 2. the duration of mood symptoms is brief compared to the entire duration of the illness. or delusions. can improve functioning and decrease relapse. with emphasis on social skills training. Extreme negativism or mutism.

Familytherapyand individual supportive psychotherapy are also useful in relapse prevention. Clinical Features of Schizoaffective Disorder A. B. Diagnosed when a manic or mixed episode occurs with psychotic features. First-degree biological relatives of schizoaffective disorder patients have an increased risk of schizophrenia as well as mood disorders. . Indications for hospitalization 1. 2.page 99. B. The illness must also be associated with delusions or hallucinations for two weeks. Diagnosed if only major depressive episodes occur. but the symptoms are also associated withrecurrentor chronic mood disturbances. Electroconvulsive therapy is rarely used in the treatment of schizophrenia.especially withahistoryofacting on hallucinations. C. The lifetime prevalence is under one percent. DSM-IV Diagnostic Criteria A. Psychotic symptoms prevent the patient from caring for his basic needs. Patients with command hallucinations to harm self or others should be evaluated for hospitalization. or mixed episode. Suicidal ideation. C. Schizoaffective Disorder I. EpidemiologyofSchizoaffectiveDisorder A. 4. Symptoms ofschizophrenia are present. Mood symptoms must be present for a significant portion of the illness. If manic or mixed symptoms occur. whichmeetsthe criteria for schizophrenia and concurrently meets the criteria for a major depressive episode. Ageneralmedical condition or substance use is not the cause of symptoms. B. without significant mood symptoms. and major depressive symptoms must be present for two weeks. B. E. III. II. Schizoaffective disorder is an illness. they must be present for one week. usually requires hospitalization. Patients who are a danger tothemselves or others require hospitalization. but may be useful when catatonia or prominent affective symptoms are present. manic episode. Major depression may also occur. D.Classification of SchizoaffectiveDisorder A. Psychotic symptoms and mood symptoms may occur independently or together. D. often secondary to psychosis. F. IV. Bipolar Type. Depressive type. 3.

D. but the duration of illness is between one to six months. . Mood disorderwithpsychotic features. Hospitalization and supportivepsychotherapy may be required. For bipolar type. E. C. mood symptoms are relatively brief in relation to psychotic symptoms.V.valproate or carbamazepine) are used alone or in combination withantipsychotics(see Mood Stabilizers. B.hallucinations. C. In schizophrenia.disorganized speech. grossly disorganized or catatonic behavior.lithium. or negative symptoms. and labs. Two or more symptoms for one month. The depressed phase of schizoaffective disorder is treated with antidepressant medications (see Antidepressant Therapy. delirium. or dementia should be ruled out by medical history. The following criteriafor schizophrenia must be met: 1. I. Psychotic and mood symptoms of schizoaffective disorder can also bemimickedbystreet drugs. Symptoms may include delusions. DifferentialDiagnosis of Schizoaffective Disorder A. Delusional Disorder. B. Psychotic symptoms are treated with antipsychotic agents (see Antipsychotic Therapy. or toxins. Mood symptoms usually do not meet the full criteria for major depressive or manic episodes. Psychotic disorder due to a general medical condition. Depressive symptoms can occur in delusional disorders. but psychotic symptoms of a delusional disorder are non-bizarre compared to schizoaffective disorder. Schizoaffective disorder and mood disorder with psychotic features must be excluded. page 107). page 111). E. VI. the psychotic features occur only inthe presence ofa major mood disturbance. mood stabilizers (eg. page 99). Substance-Induced PsychoticDisorder. Schizophreniform Disorder Patients with schizophreniform disorder meet full criteria for schizophrenia. physical exam.Treatment of Schizoaffective Disorder A. D. 2.medications. In mood disorder with psychoticfeatures. Schizophrenia. DSM-IVDiagnosticCrteriaforSchizophreniform i Disorder A. Electroconvulsive therapy may be necessary for severe depression or mania.

B. Schizophreniform disorder without good prognostic features ischaracterized by the absence of above features.3.Classification of Schizophreniform Disorder A.Treatment of Schizophreniform Disorder A. Onset of psychosis occurs within four weeks of behavioral change. Hospitalization may be required if the patient is unable to care for himself or if suicidal or homicidal ideation is present. Symptomatology must last for at least one month. Good premorbid social and occupational functioning. Early and aggressive treatment is associated with a better prognosis. Social and occupational functioning may or may not be impaired. page 99). Schizophreniform disorder with good prognostic features 1. Depressive symptoms commonly coexist and are associated with an increased suicide risk. C. The differential diagnosisfor schizophreniform disorder is the same as forschizophrenia and includes psychotic disorder due to a general medical condition. C. II. may complicate the diagnostic process. VI. Lifetime prevalence of schizophreniform disorder is approximately 0. Confusion often present at peak of psychosis. Substance abuse. 4. is the same as schizophrenia. Prevalence is the same in males and females.2%. but less than six months. Concomitant use of drugs that can cause or exacerbate psychosis. including positive and negative psychotic features. . medication or toxic substances may cause symptoms that are similar to schizoaffective disorder. B. IV. Depressive symptoms may require antidepressants or mood stabilizers. Epidemiology of Schizophreniform Disorder A. B. or dementia. 3. III. D. C. V. Clinical Features of Schizophreniform Disorder A. Differential Diagnosis of Schizophreniform Disorder A. Substance-induced symptoms or symptomsfrom a general medical condition have been ruled out. delirium. B. B. Lack of blunted or flat affect. 2. Antipsychotic medication in conjunction with supportive psychotherapy is the primarytreatment(see Antipsychotic Therapy. such as amphetamines. Symptomatology. 4.

In contrast. schizoaffective disorder. Patients with personality disorders have a higher risk for brief psychotic disorder. Duration of symptoms is between one day and one month. II. Disorganized speech. Mood and affect may be labile. diagnosis of schizophrenia requires a six-month duration of symptoms. B. Grossly disorganized or catatonic behavior. Symptom onset is often rapid. At least one of the following: 1. E. Onset is usually sudden and may abate as rapidly as it began. I. The disturbance is not caused by a mood disorder with psychotic features.Brief Psychotic Disorder Brief psychotic disorder is characterized by hallucinations.schizophrenia. Brief Psychotic Disorder with Marked Stressors is present if symptoms occur in relation to severe stressors (ie.Classification of Brief Psychotic Disorder A. Emotional turmoil and confusion are often present. 4. 3. disorganized speech or behavior. 2. B. or other medical condition. Hallucinations. The duration of symptoms is between one day and one month. III. substance abuse. Clinical Features of Brief Psychotic Disorder A. C. death of a loved one). Psychotic symptoms are usually of brief duration (several days). DSM-IV Diagnostic Criteria for Brief Psychotic Disorder A. Brief Psychotic Disorder without Marked Stressorsis presentifsymptoms occur without identifiable stressors. with marked functional impairment. B. IV. B. . D. after which the patient returns to the previous level of functioning. EpidemiologyofBriefPsychoticDisorder A. delusions. The risk of suicide is increased in patients with this disorder. with the average age of onset in the late twenties to early thirties. C. especially in young patients. Delusions. C. and younger individuals have a higher rate of illness. The disorder is rare. C. BriefPsychoticDisorderwithPostpartum Onset occurs within four weeks of giving birth. Attentional deficits are common.

such as lorazepam 1-2 mg every 4 to 6 hours. RPR to rule out neurosyphilis. such as risperidone (Risperdal) 2-4 mg per day. B.month duration. Patients can also be very confused and impulsive. especially if suicidal or homicidal ideation is present. Short-actingbenzodiazepines. Rule out with history. Mood Disorder with Psychotic Features. B. HIV to rule out psychosis due to encephalitis in at-risk patients. 4. 2. 3. Substance abuse should beexcluded byhistoryand with a urine toxicology screen. manic or mixed episode is present VI.especially when there is a history of amnestic periods or impaired consciousness. C. An EEG should be considered to rule out seizure disorders (such as temporallobe epilepsy). Differential Diagnosis of Brief Psychotic Disorder A. 2. Consider a MRI or head CT scan to rule out a mass or neoplasm. Schizophreniform disorder must last for over a month and schizophrenia must have a six.Treatment of Brief Psychotic Disorder A.V. SchizophreniformDisorderorSchizophrenia. Amphetamine. A CBC can be used torule outdeliriumand psychosis caused byinfection. cocaine and PCP mayproducesymptomsindistinguishable from brief psychotic disorder. is usually indicated. . D. Alcohol or sedative hypnotic withdrawal may also mimic these symptoms. Adjunctive benzodiazepinescan speed the resolution ofsymptoms. can be used as needed for associated agitation and anxiety.This is especially important in elderly patients where the incidence of brief reactive psychosisislowcomparedtoyounger patients. Brief hospitalization maybe necessary. Brief psychotic disorder cannot be diagnosed if the full criteria for major depressive. Routine chemistry labs can be used toruleoutelectrolyte imbalances or hepatic encephalopathy. Psychotic Disorder Caused a General Medical Condition 1. A brief course of a neuroleptic. Supportive psychotherapy is indicated if precipitating stressors are present. Substance-InducedPsychotic Disorder 1. C. Supportive psychotherapy is initiated after psychosis has resolved. physical exam and labs.

The incidence in males and females appears equal. D. Involves delusions that an individual's partner is unfaithful. Involves delusions of at least two of the above without a predominate theme. Delusional disorder is uncommon. C. Cognition and sensorium are intact. C. The insight of patients into their illness is generally poor. V. B. Mean age of onset is generallybetween 35-45.grosslydisorganized or catatonic behavior. however. Involves delusions ofexaggerated power.wealth. and this disorder may cause significant impairment in social and occupational functioning. DSM-IV Diagnostic Criteria for Delusional Disorder A. B. There is generally no disturbance of thought processes.03%. Persecutory type. Epidemiologyof Delusional Disorder A. Patient’s thoughtprocessesand thought contentare normalexceptwhen discussing the specific delusion. III. F. IV. The presence of a non-bizarre delusion is the cardinal feature of this disorder. D. C. This disorder is characterized by the absenceofhallucinations.knowledge. identity or relationship to a famous person or religious figure. B. Mixed type. Clinical Features of DelusionalDisorder A. Behavior and functioning are not significantly bizarre or impaired. D. Involves delusions that the individual is being harassed. II. Somatic type. Involves delusions of a physical deficit or medical condition. If mood episodes have occurred. the total duration of mood pathology is brief compared to the duration of the delusions.Delusional Disorder Delusional disorder is characterized by the presence of irrational. E. with prevalence of 0. The delusion must be plausible. Erotomanic type. Involves delusions that another person is in love with the patient. or negative symptoms of schizophrenia (tactile or olfactory hallucinations maybe present if related to the delusional theme). Hallucinations are not prominent unless delusional disorder is of the somatic type. untrue beliefs. such as believing that someone is trying to harm them. I. such as loosening of associations or tangentiality. Jealous type.Classification of Delusional Disorder A. Differential Diagnosis of Delusional . disorganized speech. B. age of onset is highly variable. Non-bizarre delusions have lasted for at least one month. E. Grandiose type.

Psychotherapy. B.Delusional disorder is distinguished from these disorders by a lack of other positive or negative symptoms of psychosis.Disorder A. . Psychotic Disorder Due to a General Medical Condition 1. C. Mood Disorders With Psychotic Features. Cognitive exam. historyand physical examination can usuallydistinguish these conditions. Delusional disorders are often refractory to antipsychotic medication. D. 2. Substance-InducedPsychotic Disorder 1. VI. B. see page 121. Schizophrenia/Schizophreniform Disorder. patients with delusional disorder do not meet full criteria for a mood episode and the duration of mood symptoms is brief compared to delusional symptoms. including family or couples therapy.Treatment of Delusional Disorder A. Symptoms may be identical to delusional disorder if the patient has ingested amphetamines or cocaine. 2. References References. Simple delusions of a persecutory or somatic nature are often present in delirium or dementia. Substance abuse shouldbeexcluded by history and toxicology. may offer some benefit. Although mood symptoms and delusions may be present in both disorders.

I. 9. Occasionallyno subjective depressed mood is present. D. Types of Mood Episodes a. d. b. Types of Mood Disorders a. 3. II. Symptoms cannot be caused by bereavement. Mood episodes are classified as follows: 1. Excessivegultorfeelingsofworthlessness. Other Mood Disorders. Major Depressive Episodes Major depressive episodes are characterized by persistent sadness. Mood disorders are classified as follows: 1. The mood disorders are clinical diagnoses defined by the presence of characteristic mood episodes. Mixed Episode. C. Mood episodes are not diagnostic entities. such as weight loss. . 4. E. Cannotbecausedbyamedical condition. 5. c. Sleep disturbance. Depressive Disorders. 6. c. Categorization of Mood Disorders A. B. Psychomotor agitation or retardation. Significant change in weight. Difficulty concentrating. Manic Episode. Early morning awakening with difficulty or inability to fall back asleep is typical. C. C. B. Recurrent thoughts of death or thoughts of suicide. DSM-IV Diagnostic Criteria A. Pervasive fatigue or loss of energy. F. only anxiety and irritability are displayed. Feelings of hopelessnessand helplessness are common. b. At least five of the following symptoms for at least two weeks duration. Hypomanic Episode. Symptoms must cause significant social or occupational dysfunction or significant subjective distress.Mood Disorders I. difficultysleeping and decreased energy. medication or drugs. E. Mustbe a change from previousfunctioning. Mood episodes are comprised off periods when the patient exhibits symptoms of a predominant mood state. i 8. 2. Decreased libido is common. At least one symptom is depressed mood or loss of interest or pleasure. ClinicalFeatures of Depressive Episodes A. Pervasive anhedonia. Pervasive depressed mood. Bipolar Disorders. D. Psychomotor agitation can be severe. 1. 7. B. often associated with somatic symptoms. Major Depressive Episode.

Inability to sleep can be severe and . Increased psychomotor activity can take the form of excessive planning and participation. or psychotic features are present.orhave required hospitalization to prevent harm to self or others. frequently using poor judgmentin those interactions. H. D. G. J. The patient has been more talkative than usual or feels pressure to keep talking. excessive spending. C. I. and indecisiveness. K. The most common presentation is excessive euphoria. and they are frequently nihilistic in nature. Patientsmayseek outconstantenthusiastic interaction with others. at least three of the following have persisted in a significant manner (four if mood is irritable): 1. Obsessive rumination about the past or specific problems is common. Symptoms must have cause marked impairment in social or occupational functioning. Guilt may become excessive and may appear delusional. Recklessbehaviorwthnegativeconsequences i is common (eg. Distractibility. 7. Manic Episodes I. Clinical Features of Manic Episodes A. 4. 2. Flight of ideas (jumping from topic to topic) or a subjective sense of racing thoughts. 6. At least one week of abnormally and persistently elevated. B. expansive or irritable mood (may be less than one week if hospitalization is required). Family history of mood disorder or suicide is common. The symptoms cannot be caused by a medical condition.sexual promiscuity). During the period of mood disturbance. Increased goal-directed activity or psychomotor agitation. Decreased need for sleep. medication or drugs. Inflated self-esteem or grandiosity. Does not meet criteria for a mixed episode. E. C. D. but some patients may present with irritability alone. Frank delusions and hallucinations may occur. E. Excessive involvement in pleasurable activities with a high potential for painful consequences (ie. DSM-IV Diagnostic Criteria A. sexual indiscretion). poor concentration. II.F. Preoccupation with physical health may occur. B. 3. shopping sprees. which are ultimately nonproductive. Patients mayappear demented because of poor attention. 5.

At least 4 days of abnormally and persistently elevated. J. Symptoms cannot be due to a medical condition. 4. The majordifferencebetween hypomanic and manic episodes is the lack of majorsocial and/or occupational dysfunction in hypomania. Increased goal-directed activity or psychomotor agitation. Inflated self-esteem or grandiosity. Excessive involvementin pleasurable activities that have a high potential for painful consequences (ie. Distractibility. F. During the period of mood disturbance at least three of the following have persisted in a significant manner (four if mood is irritable): 1. Patients may become assaultive. K. E. particularly if psychotic. The patient is more talkative than usual and feels pressure to keep talking. Lability of mood is common. Speech is pressured. and the patient may become suicidal. The mood disturbance and change in functioning is noticeable to others. Hallucinations and delusions are not seen in hypomania. 7. II. 5. most frequently with paranoid features. and no psychotic features are present. which is hallmark of a manic episode. medication or drugs. Decreased need for sleep. Flight of ideas (jumping from topic to topic) or a subjective sense of racing thoughts. D. expansive or irritable mood. G. . H. and difficulty to interrupting these patients is common. B. Patients frequently lack insight into their behavior and resist treatment. L. Flight of ideas can result in gross disorganization and incoherence of speech. Hypomanic Episodes I. loud and intrusive.does notrequirehospitalization. The change in functioningisuncharacteristic of the patient’s baseline but does notcause marked social or occupational dysfunction. Grandiose delusions are common. 3. 2. Dysphoria is common at the height of a manic episode.persist for days.sexual promiscuity). C. Patients maybecome grosslypsychotic. 6. DSM-IV Diagnostic Criteria A. Clinical Features of Hypomanic Episodes A. I.

such as myocardial infarction. Major depressive disorder has a high mortality. This rises to 70% after two episodes and 90% after three episodes. . Historyof one or more Major Depressive Episodes. medications. allowing patients to follow through on suicidal ideas. with a 2:1 female-to-male ratio. DSM-IV Diagnostic Criteria A. C. Hospitalization may be necessary for acutely suicidal patients. Epidemiology of Major Depressive Disorder A. such as loss of a loved one. Suicide risk is most closely related to the degree of hopelessness a patient is experiencing and not to the severity of depression. II. B.suicidality. DSM-IV Diagnostic Criteria for Major Depressive Disorders A. All patients should be asked about suicidal ideation as well as intent. stroke.appetite disturbance and insomnia Major Depressive Disorder I. and diabetes. Common coexisting diagnoses include panic disorder. These disorders should be excluded by the clinical history. B. Major depressivedisorderoftencomplicates the presentation and treatment of patients with medical conditions. C. No history of manic. Organic factors have been excluded (medical conditions. eatingdisorders. psychosis. 15% suicide rate. drugs). or mixed episodes. II. Patient meets criteria for both for at least one week. Symptoms are severe enough to cause marked impairmentinoccupational or social functioning. D.require hospitalization. III. Clinical Features of Mixed Mood Episodes A. B.Mixed Mood Episodes I. E. Theyfrequentlypresent with agitation. Suicide risk may increase as the patient begins to respond to treatment. Prevalence is approximately 3-6%. or psychotic features are present.substance-related disorders. The disorder often follows an episode of severe stress. Patients subjectivelyexperience rapidly shifting moods. Clinical Features of Major Depressive Disorder A. Approximately 50% of patients who haveasingleepisode ofmajor depressive disorder will have a recurrence. hypomanic. B. Lack of initiative and poor energy can improve prior to improvement in mood. B.

Major Depressive Disorder with Seasonal Pattern 1. Recurrent episodes of depression with a pattern of onset at same time each year. stereotyped movement. resulting in significant social or occupational dysfunction. The disorder is two times more common in first-degree relatives of patients withmajor depressive disorder compared to the general population. 2. 6. Echolalia or echopraxia. Depression is accompanied by mood reactivity and at least two of the following: 1. 5. 2. Does not meet criteria for major depressive disorder with melancholic or catatonic features. Full remissions occur ata characteristic time of year. 5. Motor immobility or stupor. Functioning returns to the premorbid level between episodes in approximately two-thirds of patients.C. Chronic patternof rejection sensitivity. Bizarre or inappropriate posturing. C. Excessive purposeless motoractivity. Major Depressive Disorder. Qualityofmood is distinctlydepressed. or facial grimacing. “Heavy”feeling in extremities (leaden paralysis). Major Depressive Disorder with Psychotic Features. F. 4. Significant weight loss. Depression is accompanied by hallucinations or delusions. G. Extreme negativism or mutism. Early morning awakening. . Fulldiagnosticcriteriafor major depressive disorder have been met continuously for at least 2 years. IV. 4. Major Depressive Disorder with Melancholic Features. Mood is worse in the morning. Marked psychomotor slowing. E. Excessive guilt. Significant weight gain.Chronic. 5. D.Classification of Major Depressive Disorder A. 4. 3. Major Depressive Disorder with Catatonic Features Accompanied by at least two of the following: 1. 3. B. D. 3. Hypersomnia. 2.whichmaybemood-congruent (content is consistent with typical depressive themes) or mood incongruent (content does notinvolve typicaldepressive themes). 2. Major Depressive Disorder with Atypical Features. Major Depressive Disorder with Postpartum Onset.Onset ofepisode within four weeks of parturition. Depression is accompanied by severe anhedonia or lack of reactivityto usuallypleasurable stimuli and at least three of the following: 1.

The medical historyand examination can suggest possible medical . and impaired memory. at least twoseasonal episodes haveoccurred. E. V. 2. Schizophrenia and Schizoaffective Disorder 1. 3. Differentiation of dementia from depression can be very difficult in the elderly. 2. 4. Antidepressants are often effective in treating anxiety disorders. Symptoms of anxiety frequently coexist with depression. D. the depression should be the focus of treatment because it carries a higher morbidity and mortality. the mood symptoms generally precede the onset of psychotic symptoms. compared to patients with psychotic disorders. Dementia and depression may present with complaints of apathy. 2. Subjectivedepression mayaccompany acute psychosis. however. Bereavement 1. Anxiety Disorders 1. 2. Normal bereavement should not present with depressive symptoms. “Pseudodementia” is defined as depression that mimics dementia. which cause severe functional impairment lasting more than two months. a trial of antidepressants maybe useful because depression is reversible and dementia is not. Over a two-year period. and no nonseasonal episodes have occurred. Severe psychotic depressionmaybedifficulttodistinguish from a primary psychotic disorder. dysphoria related to a stressor that does not meet the criteria for major depressive episode should be diagnosed as an adjustment disorder. When the diagnosis is unclear. C. The premorbid and inter-episode functioning are generally higher in patients with mood disorders. Adjustment Disorderwith Depressed Mood 1. Differential Diagnosis of MajorDepressive Disorder A. Dementia 1. Cognitive deficits due to a mood disorder may appear very similar to dementia. 3.3. B. 4. Seasonal episodes outnumber non-seasonal episodes. poor concentration. A stressful event may precede the onset of a major depressive episode. When anxiety symptoms coexist with depressive symptoms. In psychotic depression. Bereavement may share many symptoms of a major depressive episode.

The medical historyand examination may suggest potential medical conditionswhich present with depressive symptoms. Substance-Induced Mood Disorder 1. making them preferable for suicidal patients. a. page 107. Selective-serotonin reuptake inhibitors (SSRIs) are much safer in patients with a history of cardiac disease. or toxin exposure should be completed. Selecting an Antidepressant Agent 1. Heterocyclic Antidepressants a. another trial of that medication is indicated. 2. Side effects (especiallysedation and anticholinergic effects) are worse during the first month of therapy and usuallydiminish after four weeks. Mood Disorder Due to a General Medical Condition 1. the patient's age. All antidepressant drugs have shown equal efficacy. which isnotsimplya reaction to the disability of the disease. drugs of abuse. suicide potential. F. but the various agents have different side-effect profiles. Early in the treatment course. For example. Withdrawal from sympathomimetics or amphetamines may cause a depressive syndrome.or organic causes of dementia. Agent selection is also based on the expected tolerance to side effects. 3.If the patient or a first-degree relative has had a previous treatment response to a given medication. b. sedatives. Alcohol. drug abuse.seeAntidepressant Therapy. Careful examination ofall medications. Parkinson’s disease is oftenassociated with a depressive syndrome. For a complete discussion of the treatmentofDepression. C.Pharmacotherapy of Depression A. and anycoexisting diseases or medications. antihypertensives. 2. 2. SSRIs are safer than heterocyclic antidepressants in overdose. b. G. This diagnosis applies when the mooddisorder is a directphysiological consequence of the medicaldisorder and is not an emotional response to a physical illness. VI. but patients rarelydescribeimprovement .and oralcontraceptives can all cause depressive symptoms. There is no reliable method of predicting which patients will respond to a specific antidepressant based on clinical presentation. 3. Classification of Antidepressant Agents 1. B. patients may sleep better.

and is particularly useful in patients who have had sexual impairment from other drugs. Selective-Serotonin Reuptake Inhibitors (SSRIs) a. agitation. SSRIs are commonly used as first-line agents as well as secondarychoices for depression thatdoes not respond to tricyclics.andescitalopram (Lexapro).in mood before 3-4 weeks. d. nervousness and nausea are common. with their comparatively benign side-effect profile. Effexor XR): Venlafaxine is a selective inhibitor of norepinephrine and serotonin reuptake. and sexual dysfunction. Only minimum quantities of tricyclics should be prescribed because of the potential of tricyclicstocause a fatal overdose in suicide-prone patients. c. There is a low incidence of sexual dysfunction and decreased liability to precipitate mania. Atypical Agents a. Venlafaxine (Effexor. Useofheterocyclic antidepressants in the elderly may be limited bythe sensitivityof these patients toanticholinergic and cardiovascular side effects. Thus. c. Although many patients take SSRIswithnoadverseconsequences. It tends to be more sedating than the SSRIs. citalopram(Celexa). c. SSRIs. and it can have a calming or antianxiety effect in some patients. b. At higher doses it can elevate diastolic blood pressure and requires monitoring of blood pressure. SSRIs include fluoxetine(Prozac). the most frequent side effects are insomnia. Bupropion (Wellbutrin. The short half-life of bupropion requires multiple dailydoses. a therapeutic dose may be achieved earlier than with tricyclics. fluvoxamine (Luvox). anxiety. Nefazodone(Serzone):Nefazodone is a serotonergic antidepressant. 3. paroxetine (Paxil). GI upset.complicatingcompliance. It is also useful . headache. sertraline (Zoloft). d. 2. Another advantage of SSRIs is that they require less dosage titration. b. e. Wellbutrin SR):Bupropion is a mildlystimulating antidepressant. allow once-daily dosing and present less danger from overdose because theylackthecardiovascular toxicity of the tricyclics. Insomnia. but it is not considered a SSRI becauseofother receptor effects.

5. after ETC. Mirtazapine(Remeron):Mirtazapine is a selective alpha-2 adrenergic antagonist. Poor appetite or overeating. for more days than it is not present. Marked sedation often occurs. A wide variety of psychotherapies are effective in the treatment of major depressive disorder. SideEffects.000-300. 3. DSM-IV Diagnostic Criteria A. c. B. There is a lowincidence of sexual dysfunction. Drug Interactions.in patients who experience sexual impairment with other antidepressants.Orthostatichypotension is common. 4. B. Weight gain is also common (average of 2 kg). Hopelessness. Insomnia or hypersomnia. Depressed mood is present for most of the day.000 patient-years of nefazodone exposure). and SSRIs can be life-threatening. which usually decreases over the first weeks of treatment. PsychotherapyforMajorDepressive Disorder A. especiallycognitive behavioral psychotherapy and insight oriented psychotherapy. Dysthymic Disorder I. ECT is a safe and very effective treatment for depression. and depression has been present for at least two years. VII. Rare cases ofliver failurehave been reported with nefazodone (one case of death or liver transplant per 250. b. Low self-esteem. Monoamine Oxidase Inhibitors a.Coadministration of epinephrine. Presence of at least two of the following: 1. Poor concentration or difficulty making decisions. 2. page 119). A tyramine-free dietisrequiredtopreventhypertensive crisis. which enhances noradrenergic and serotonergic neurotransmission. d. VIII. 6. Combined pharmacotherapy and psychotherapy is the most effective treatment for major depressive disorder. Low energy or fatigue. ElectroconvulsiveTherapyforDepression (also see Electroconvulsive Therapy. . meperidine (Demerol). 4. especially if there is a high risk for suicide or insufficient time for a trial of medication. Contraindications and dietary restriction discourage common use.

D. Changesinsleep. Lifetime prevalence is 6%. Epidemiologyof Dysthymic Disorder A. guilt. Hypersomnia. 4. Significant weight gain. Early Onset Dysthymia: Onset occurs before age 21. B. . which often results in significant social or occupational dysfunction. Differential Diagnosis of Dysthymic Disorder A. Symptoms are not due to substance use or a general medical condition. B. social withdrawal. with a female-to-male ratio of 3:1. The most common symptoms are loss of pleasure in usually pleasurable activities. or evidence of cyclothymia is present. F. Over the two-year period. and decreased productivity. B. the patient has never been without symptoms for more than two months consecutively. Symptoms do not occur with a chronic psychotic disorder. characterized by a feeling of being heavy or weighted down physically. The combination of dysthymia and major depression is known as “double depression.” III. IV. No manic. Late Onset Dysthymia: Onset occurs at age 21 or older. MajorDepressiveDisorder.C. H. G. Onset usually occurs in childhood or adolescence. feelings of inadequacy. Psychotic symptoms are not present. D. Achronic patternofrejection sensitivity. E. “Leaden” paralysis. Dysthymia that occurs prior to the onset of major depression has a worse prognosis than major depression without dysthymia. which may interfere with occupational or social functioning. Major Depression usually has one of more discrete episodes. C. appetite orpsychomotor behavior are less common than in major depressive disorder. Dysthymia with Atypical Features is accompanied by mood reactivity and at least two of the following: 1. No major depressive episode has occurred during the first two years of the disturbance. less severe depressive symptoms. irritability. comparedtoMajor Depression. B. 3. II. Patients often complain of multiple physical problems. Symptoms of dysthymic disorder are similar to those of major depression. V. C. 2. C.Classification of Dysthymic Disorder A.Dysthymia leads to chronic. Substance-Induced Mood Disorder. Episodes of major depression may occur after the first two years of the disorder. Symptoms cause significant social or occupational dysfunction or marked subjective distress. Clinical Featuresof Dysthymic Disorder A. hypomanic or mixed episode.

Anabolic steroids.oral contraceptives. D. as can chronic use of amphetamines or cocaine. have failed. Antidepressants. Parkinson’s disease. Insight oriented psychotherapy may help patients resolve early childhood conflict. E. physical examination. If these or other antidepressants. Mood Disorder Due to a General Medical Condition. 150 to 200 mg per day.Substance-Induced Mood Disorder should be excluded with a careful historyof drugs of abuse and medications. C. SSRIs are most often used.Alcohol. Combined psychotherapy and pharmacotherapy produces the best outcome. (For a complete discussion of antidepressant therapy. which may have precipitated depressive symptoms. Hospitalization is usually not required unless suicidality is present.Cushing’s disease. then a tricyclic antidepressant. is often effective. Many patients respond well to antidepressants. methyldopa. benzodiazepines and other sedative-hypnotics can mimic dysthymia symptoms. . such as venlafaxine. page 107) C. Personality Disorders.hypothyroidism. B. beta-adrenergicblockersand isotretinoin (Accutane) have also been linked todepressivesymptoms. Psychotic Disorders. pancreatic carcinoma. Psychotherapy:Cognitivepsychotherapy may help patients deal with incorrect negative attitudes about themselves. and labs as indicated. vitamin B12 deficiency. and HIV. Depressive symptoms are common in chronic psychotic disorders. nefazodone or bupropion.Depressivesymptoms consistent with dysthymia may occur in stroke. and dysthymia should not be diagnosed if symptoms occur only during psychosis. These disorders should be ruled out with a history. multiple sclerosis. VI. such as desipramine.Treatment of Dysthymic Disorder A. Huntington’s disease. Personality disorders frequentlycoexist withdysthymic disorder.

or divorce. E. D. F. hypomanic.5-1. IV. First-degree relatives have higher rates of mood disorder. The suicide rate of bipolar patients is 10-15%. D. B. child abuse. The disorder is commonlyaccompanied by a history of one or more major depressive episodes. III. Bipolar I Disorder with Rapid Cycling 1. C. Symptoms cannot be caused by a psychotic disorder. Epidemiology of Bipolar I Disorder A. The most recent episode can be further classified as follows: 1. 2. and attention deficit hyperactivity disorder. Episodes occur more frequently with age. One or more manic or mixed episodes. Bipolar disorder has a 70% concordance rate among monozygotic twins. Mixed episodes are more likely in younger patients. job loss. 3. eating disorders. 4. medication. but a major depressive episode is not required for the diagnosis. C. Classification of bipolar I disorder involves describing the current or most recent mood episode as either manic. Diagnosis requires the presence of at least four mood episodes within one year. excessive debt.5%. Manic episodes can result in violence. drugs of abuse. Ninety percent of patients who have a single manic episode will have a recurrence. Without psychotic features. D. toxins. With postpartum onset. . B. Bipolar I disorder with a rapid cycling pattern carries a poor prognosis and mayaffect up to 20% of bipolar patients.Classification of Bipolar I Disorder A. Manic or mixed episodes cannot be due to a medical condition. I. C. B. Bipolar I disorder. Clinical Features of Bipolar I Disorder A. With catatonic features. The male-to-female ratio is 1:1 C. G. II. B. mixed or depressive (eg.Bipolar I Disorder Bipolar I Disorder is a disorder in which at least one manic or mixed episode is present.most recent episode mixed). or treatment for depression. The first episode in males tends to be a manic episode. DSM-IV Criteria for Bipolar I Disorder A. The lifetime prevalence of bipolar disorder is approximately 0. Common comorbid diagnoses often include substance-related disorders. With psychotic features. while the first episode in females tends to be a depressive episode.

cocaine. (Also see Mood Stabilizers. The patient must be symptom-free for at least two months between episodes. V. or major depression.Treatment of Bipolar I Disorder A. Antidepressants may be used for treatment of major depressiveepisodes. Medical conditions that maypresent with manic symptoms include AIDS. such as lithium and the anticonvulsants. If the history is unavailable or if the patient is having an initial episode. Differential Diagnosis of Bipolar I Disorder A. page 111). or the patient must switch to an opposite episode. cimetidine). indicates that a mood disorder. A family history of either a mood disorder or psychotic disorder suggests the diagnosis of bipolar disorder or psychotic disorder respectively. This disorder may cause manic-like episodes that do not meet the criteria for manic episode. Pharmacotherapy 1. and brain tumors. mpat amphetamines. is present. multiple sclerosis. Mood stabilizers. hyperthyroidism. The effects of medication or drugs of abuse should be excluded. but they should only be used in . 3. 3. 2. Rapid cycling mood episodes may include major depressive. hypomanic. The clinical presentation of a patient at the height of a manic episode may be indistinguishable from that of an acute exacerbation of paranoid schizophrenia. Cyclothymic Disorder. are effective for acute treatment as well as the prophylaxis of mood episodes. and H2 blockers (eg. butitisgenerallyused after conventional pharmacotherapy has failed or is contraindicated. Substance-Induced Mood Disorder. rather than a psychotic disorder. B. Psychotic Disorders 1. VI. depressive episodes. ECT is very effective for bipolar disorder (depressed or manic episodes). Cushing’s.2. B. Assessment of suicidality is essential. A subsequent major depressive episode or manic episode that initially presents with mood symptoms prior to the onset of psychosis. Hospitalization may be necessary for either Manic or Depressive mood episodes. C. steroids. lupus. or mixed episodes 3. Mood Disorder Due to a General Medical Condition. Common organiccausesofmaniaincludesy homimetics. 2. C. D. it may be necessary to observe the patient over time to make an accurate diagnosis. manic. suicidal ideation and intent should be evaluated.

Antidepressants mayinduce rapid cycling. It is more common in women than in men. Bipolar IIDisorder with Rapid Cycling 1. Social and occupational consequences of bipolar II can include job loss and divorce. and borderline personality disorder. 3. 4.Otheratypical antipsychotics are likely to have similar efficacy.Olanzapine (Zyprexa) is FDA approved for the treatment ofacutemania. The most recent episode can be further classified as follows: 1.conjunction with a mood stabilizer to prevent precipitation of a manic episode. eating disorders. D. One ormore majordepressiveepisodes and at least one hypomanic episode. Common comorbid diagnoses include substance-related disorders. C. toxins. DSM-IV Diagnostic Criteria of Bipolar II Disorder A. which can be hypomanic or depressive. 2. Bipolar II Disorder I. Epidemiology. 2. Episodes without psychotic features. attention deficit hyperactivity disorder. B. IV. Symptoms cannot be caused by a psychotic disorder. or treatment for depression.Classification of Bipolar II Disorder A.5%. maybe necessary. D.such as clonazepam and lorazepam (for severe agitation). medication. This diagnosis requires the presence of at least four mood episodes within one year. Episodes with psychotic features. III. 4. Mood episodes cannot be caused by a medical condition. C. and episodes tend to occur more frequently with age. Adjunctive use of antipsychotics (if psychosis is present) or sedating benzodiazepines. II. C. Hypomanic episodes tend to occur in close proximitytodepressiveepisodes. Family or marital therapy may also help increase understanding and tolerance ofthe affected familymember. drugs of abuse. The rapid cycling pattern carries a poor prognosis. B. The lifetime prevalence of bipolar II is 0. Episodes with catatonic features. Clinical Features of Bipolar II Disorder A. B. Classification of bipolar II disorder involves evaluation of current or most recent mood episode. Psychotherapy 1. Therapy aimed at increasing insight and dealing with the consequences of the manic episodes may be very helpful. Episodes may include . These patients have a suicide rate of 10-15%. Episodes with post partum onset.

mania or mixed states were present. Cyclothymic Disorder Cyclothymic disorder consists of chronic cyclical episodes of mild depression and symptoms of mild mania. Symptoms cause significant distress or functional impairment. drugs of abuse. Depressivesymptoms consistent with dysthymia may occur in stroke. F. no episodes of major depression. B. Patients frequently have coexisting . Symptoms are not accounted for by schizoaffective disorder and do notcoexistwithschizophrenia. Treatment is similar to that of Bipolar I disorder. Differential Diagnosis of Bipolar II Disorder A.Cushing’s disease. II. or mixed type episodes. DSM-IV Diagnostic Criteria A. or the patient must display a change in mood to an opposite type of episode. V. Parkinson’s disease. During the two-year period.Depressive episodes do not reach the severity of major depression. Manic symptoms can be associated with AIDS.schizophreniform disorder.Treatment of Bipolar II Disorder. D. 2. hypomanic. Symptoms are similar to those of bipolar I disorder. Symptoms are notcaused bysubstance use or a general medical condition. Cyclothymic Disorder. described above (See Mood Stabilizers. The patient must be symptom-free for at least two months between episodes. B. and HIV. or any other psychotic disorder. Cushing’s. I. During the two-year period. hyperthyroidism. C. but they are of a lesser magnitude and cycles occur at a faster rate. Substance-Induced Mood Disorder.major depressive. Manyperiods ofdepression and hypomania. vitamin B12 deficiency. manic. occurring for atleasttwo years. delusional disorder. The treatment of Bipolar II disorder includes a mood stabilizer and an antidepressant if depression is present. or toxin exposure should be excluded. pancreatic carcinoma.hypothyroidism. ClinicalFeaturesof Cyclothymic Disorder A. C. multiple sclerosis. page 111). Mood Disorder Due to a General Medical Condition. These patients will exhibit mood swings that do not meet the criteria for full manic episode or full major depressive episode. and brain tumors. The effects of medication. Huntington’s disease. lupus. E. the patient has not been symptom-free for more than two months at a time. B.multiplesclerosis. VI.

One-third of patients develop a severe mood disorder (usually bipolar II). D. Cyclothymic disorder often coexists with borderline personality disorder. Occupational and interpersonal impairment is frequent and usually a consequence of hypomanic states. (Also see Mood Stabilizers. Huntington’s disease.Antidepressants can also increase the rate of cycling.multiple sclerosis. Thirty percent of patients have a family history of bipolar disorder.Cushing’s. References References. C. Treatment of Cyclothymic Disorder A. B. borderline. B. C. page 111). Hypomanic symptoms canbe associated with AIDS. Epidemiologyof Cyclothymic Disorder A.hypothyroidism. histrionic. Personality Disorders (antisocial. and women are affected more than men by a ratio of 3:2. B. C. Patients are often treated concurrently with antimanics and antidepressants. III. Bipolar II Disorder.Depressivesymptoms consistent with dysthymia may occur in stroke. Depressive episodes must be treated cautiouslybecause ofthe risk ofprecipitating manic symptoms with antidepressants (occursin50%ofpatients).lupus. The onset occurs between age 15 and 25. The prevalence is 1%. and brain tumors. Patients with bipolar type IIdisorder exhibit hypomania and episodes of major depression. but cyclothymic disorder constitutes 5-10% of psychiatric outpatients. narcissistic) can be associated with marked shifts in mood. The clinical use of mood stabilizers is similar to that of bipolar disorder. see page 121. and lithium is effective in 60% of patients. Patients often require supportive therapy to improve awareness of their illnessand todealwiththe functional consequences of their behavior. multiple sclerosis.Differential Diagnosis of Cyclothymic Disorder A.substance abuse.Cushing’s disease. E. hyperthyroidism. . and HIV. Parkinson’s disease. pancreatic carcinoma. vitamin B12 deficiency. V. Substance-InducedMoodDisorder/Mood Disorder Due to a General Medical Condition. C. IV. Personality disorders may coexist with cyclothymic disorder. Mood stabilizers are the treatment of choice.

It is characterized by unrealistic or excessive anxiety and worry about two or more life circumstances for at least six months. abdominal pain. muscle twitches. The anxiety is difficult to control. and diarrhea.and symptoms are not related to a mood or psychotic disorder. muscle aches and soreness. Drugs and alcohol may cause anxiety or may be an attempt at self-treatment. C. B. Patients may also report palpitations. DSM-IV Diagnostic Criteria for Generalized Anxiety Disorder A. health.light-headedness. D. and a heightened startle reflex. clammy hands. 3. Sleep disturbance. E. Excessive worry and somatic symptoms. Substance abuse maybe acomplication . About 30-50% of patients with anxiety disorders will also meet criteria for major depressive disorder. Other features often include insomnia. marriage. jobs. 5. unlike the intermittent terror that characterizes panic disorder. Muscle tension.” which mayrevolve around valid concerns about money. and the safety of children. difficultybreathing. Chronic worry is a prominent feature of generalized anxiety disorder. Difficulty concentrating.dysphagia. B. 4. Up to one-fourth of GAD patients develop panic disorder. Excessive anxiety or worry is present most days during at least a six-month period and involves a number of life events. At least three of the following: 1. Restlessness or feeling on edge.Anxiety Disorders Generalized Anxiety Disorder Generalized anxiety disorder (GAD) is the most common of the anxiety disorders. as in panic disorder. trembling. Clinical Features of Generalized Anxiety Disorder A. Symptoms are notcaused bysubstance use or a medical condition. 6. I. including autonomic hyperactivity and hypervigilance. E. urinaryfrequency. 2. The focus of anxiety is not anticipatory anxiety about having a panic attack. dry mouth.dizziness. The anxiety or physical symptoms cause significant distress or impairment in functioning. dyspepsia) commonly coexist with GAD. D. occur most days. F. irritability.substance-andstress-related disorders (headaches. Irritability. Easy fatigability. Mooddisorders. Patients often complain that they “can't stop worrying. C. II.

For example. The female-to-male sex ratio for GAD is 2:1. Substancessuchascaffeine. calcium and phosphate levels.of GAD. IV. 2. D. Substance-Induced AnxietyDisorder. C. congestiveheartfailure.amphetamines. If anxiety occurs only during the course of the mood or psychotic disorder. B. Many psychiatric disorders present with marked anxiety.Hypochondriasis and Anorexia Nervosa 1. Panic Disorder. Alcohol or benzodiazepine withdrawal can mimic symptoms of GAD.SocialPhobia. or cocaine can cause anxietysymptoms. however. These disorders should be excluded byhistory and toxicology screen. Venlafaxine is a first-line treatment for GAD. and hypoglycemia.pulmonaryembolism. or if an anorexic patient has anxiety about weight gain. GAD should not be diagnosed in panic disorder if the patient has excessive anxiety about having a panic attack. Other Studies. cardiac arrhythmias. and thyroid studies should be included in the initial workup of all patients. B. 2.Treatment of Generalized Anxiety Disorder A. then GAD cannot be diagnosed. patients with severe anxiety or panic attacks should be . C. Anxiety Disorder Due to a General Medical Condition. Excessive worryand anxietyoccurs inmanymood and psychotic disorders. Lifetime prevalence is 5%. Pharmacotherapy of Generalized Anxiety Disorder 1. Most patients report excessive anxiety during childhood or adolescence. V. electrocardiogram. Epidemiology A. onset after age 20 may sometimes occur. Serum glucose. The combination of pharmacologic therapy and psychotherapy is the most successful form of treatment.and the diagnosis of GAD should be made only if the anxiety is unrelated to the other disorders.Obsessive-Compulsive Disorder. Venlafaxine (Effexor and Effexor XR) a. B. B. Effexor XR can be started at75 mg perday. III. Laboratory Evaluation of Anxiety A. Hyperthyroidism. Urine drug screen and urinary catecholamine levels may be required to exclude specific disorders. VI.Differential Diagnosis of Generalized Anxiety Disorder A.however. may produce significant anxiety and should be ruled out as clinicallyindicated. Mood and Psychotic Disorders 1.

Benzodiazepines are veryuseful for treating anxiety during the period in which ittakes buspirone or antidepressants to exert their effects. Other Antidepressants a. or who are intolerant to their side effects. b. There is no physiologic dependence or withdrawal syndrome. Tolerance tothe beneficial effects ofbuspirone does not seem to develop. c. Their onset of action is much slower than thatofthe benzodiazepines.started at 37. Antidepressants are especially useful in patients with mixed symptomsofanxietyanddepression.5 mg per day. Combinedbenzodiazepine-buspirone therapymaybeused for generalized anxietydisorder. The side effect profile for GAD patients is similar to that seen with depressive disorders. and they have no delayed onset of action. buttheyhave no addictivepotential and may be more effective.withsubsequent tapering of the benzodiazepine after 2-4 weeks. Long-term useofbenzodiazepines should be reserved for patients who have failed to respond to venlafaxine (Effexor). An antidepressant is the agent of choice when depression coexists with anxiety. Benzodiazepines can almost always relieve anxiety if given in adequate doses. The dose should then be titrated up to a maximum dosage of 225 mg of Effexor XR per day. d. 4. Venlafaxine usually requires several weeks to achieve efficacy and an adequate trial should last for 4-6 weeks. Buspirone is a first-line treatment of GAD. SSRIs. 3. b. Benzodiazepines . Selective-serotonin reuptake inhibitors and tricyclic antidepressants are widely used to treat anxiety disorders. b. c. Buspirone (BuSpar) a. Buspirone may have some antidepressant effects. 2. It lacks sedativeeffects. Benzodiazepines a. SSRIs appear to have similar efficacytovenlafaxine and should also be considered as a first-line therapy. Buspirone usually requires 3-6 weeks at a dosage of 10-20 mg tid for efficacy. Patients who have been previously treated with benzodiazepines or who have a historyofsubstance abuse have a decreasedresponse to buspirone. buspirone (BuSpar) and other antidepressants. b. c.

C.should then be tapered after several weeks. b. withthe use ofmedication ifnecessary. Sensation ofshortness of breath.characterized byintense anxiety. f. lightheaded or . mayimprove functioning in mild cases. Nausea or abdominal distress. Chest pain or discomfort. Tolerance to their sedative effects develops. Sweating. b. I. Feeling of choking. f. d. but not to their antianxiety properties. andavoidexcessivealcoholconsumption. Both 1 and 2 are Required 1. Palpitations. Moderate exercise each day may help reduce the intensity of anxiety symptoms. Recurrent unexpected panic attacks occur. Patients should get adequate sleep. Trembling or shaking. Benzodiazepines have few side effects other than sedation. Cognitive behavioral therapy.Awithdrawal syndrome occursin70%ofpatients. increased heart rate. 3. e. h. with emphasis on relaxation techniques and instruction on misinterpretation ofphysiologic symptoms. Drug dependency becomes a cinicalissueifthebenzodiazepine l is used regularly for more than 2-3 weeks. Psychotherapy a. Supportive or insight oriented psychotherapy can be helpful in mild cases of anxiety. Slowtapering ofbenzodiazepines is crucial (especially those with short half-lives). Patients should stop drinking coffee and other caffeinated beverages. DSM-IV Criteria for Panic Disorder with Agoraphobia A. 2. Non-Drug Approaches to Anxiety 1. which are almost intolerable. g. during which four of the following symptoms begin abruptly and reach a peak within 10 minutes in the presence of intense fear: a. Feeling dizzy. they are less likelyto result in interdose anxiety and are easier to taper. d. c. Panic Disorder Patients with panic disorder report discrete periods of intense terror and fear of impending doom.tremulousness dysphoria. Since clonazepam (Klonopin) and diazepam (Valium) have long half-lives. e. sleep and perceptual disturbancesandappetitesuppression.

Elevation ofblood pressure and tachycardia may occur during a panic attack. Agoraphobia may develop in patients with simple panic attacks. B. such as social phobia. At least one of the attacks has been followed by one month of one of the following: a. Anxiety about being in places or situations where escape might be difficult or embarrassing.Epidemiology of Panic Disorder . 3. Marked anxiety about having future panic attacks (anticipatoryanxiety) is common.faint. DSM-IV Criteria for Panic Disorder without Agoraphobia. such as panic on exposure to social situations in social phobia. and phobic avoidance to these situations can occur. Situations are avoided or endured with marked distress. C. C. A significant change in behavior related to the attacks. i. or panic in response to stimuli of a severe stressor. panic attacks may occur in relation to specific situations. the most common fears are of being outside alone or of being in crowds or traveling. The DSM-IV diagnostic criteria are the same as panic disorder with agoraphobia. II. Worry about the implications of the attack. or these situations require the presence of a companion. b. The presence of agoraphobia that has the following three components: 1. D. Later in the disorder. III. In agoraphobia. or these situations are endured with anxiety about developing panic symptoms. 2. The first panic attack often occurs without an acute stressor or warning. Fear of dying. j. Panic attacks are not due to the effects of a substance or medical condition. Fear of losing control or going crazy. Patients often believe that they have a serious medical condition. c. except there are no symptoms of agoraphobia. such as with post-traumatic stress disorder. B. The panic attacks are not caused by another mental disorder. l. such as fear of having a heart attack or going crazy. 2. k. IV. The anxiety is not better accounted for by another disorder. Major Depression occurs in over fifty percent of patients. Persistent concern about having additional attacks. m. Paresthesias. where phobicavoidance is only limited to social situations. or in which help might not be available. Derealization or depersonalization. Chills or hot flushes. Clinical Features of Panic Disorder A.

Physiologic withdrawalfromalcohol. These panic attacks occur immediately after exposure to the feared stimulus.benzodiazepines or barbiturates can also precipitate panic attacks. C. Panic disorder is characterized by discrete episodes of severe anxiety along with physiologic symptoms.Substance abuse. Substance-InducedAnxietyDisorder. Fifty percent of panic disorder patients are only mildlyaffected. hyperthyroidism. pulmonary embolism and hypoxia can present with symptoms similar to panic attacks. Pheochromocytoma may mimic panic disorder and is characterized by markedly elevated blood pressure during the episodes of anxiety. These panic attacks occur spontaneously without any situational trigger. E. The course of the illness is often chronic. but symptoms may wax and wane depending on the presence of stressors. D. may occur in up to 40% of patients. These panic attacks usually occur upon exposure to the feared stimulus. .Differential Diagnosis of Panic Disorder A. Panic disorder usually develops in early adulthood with a peak onset in the mid twenties. B. The lifetime prevalence of panic disorder isbetween1. V.Thefemale-to-male ratio is 3:1. Anxiety Due to a General Medical Condition.5%. B. cocaine or caffeine can mimic panic attacks. Onset after age 45 years is unusual. Amphetamines. such as being in a high place or in an elevator. Cardiac arrhythmias. Anxiety is more constant than in panic disorder. Classification of Panic Disorder A.A. Situationally Bound Panic Attacks. C. especiallyin untreated patients.5%and3. VI. B. but he may not have an attack in every situation. an individual may have panic attacks in crowded situations. It is excluded by a 24-hour urine assay formetanephrineorbyserumcatecholamines. Unexpected Panic Attacks. but they do not necessarily occur immediatelyafter everyexposure. Generalized AnxietyDisorder. Twentypercent have marked symptomatology. especially of alcohol. For example. First-degree relatives have an eightfold increase in panic disorder. Up to one-half of panic disorder patients have agoraphobia. C. The suicide risk is markedly increased. Situationally Predisposed Panic Attacks. or the attack may occur only after spending a significant amount of time in a crowded location.

and it should be started at 10-25 mg per day. A long-acting agentsuch as clonazepam (Klonopin) is also effective. 3. Mild cases of panic disorder can be effectivelytreated with cognitivebehavioral psychotherapy with an emphasis onrelaxationandinstructiononmisinterpretation of physiologic symptoms. Benzodiazepines may be used adjunctively with TCAs or SSRIs during the firstfewweeks of treatment. When a patient has failed other agents. Imipramine (Tofranil) is the best studied agent. such as 5-10 mg of paroxetine (Paxil) or 12. Fluoxetine (Prozac) mayexacerbate panic symptoms unless begun at very low doses (2-5 mg). When using a tricyclic antidepressant. . Pharmacotherapy is indicated when patients have marked distress from panic attacks or are experiencing impairment in work or social functioning. 7. A low dose.VII. 4. and it causes less interdose anxiety compared to alprazolam. The dose may then be gradually increased up to 20-40 mg for paroxetine or 50 to 100 mg for sertraline. but these agents are not often used because ofconcern over hypertensive crisis when patients do not follow a low tyramine diet. Alprazolam(Xanax) should be givenfour times a dayto decrease interdose anxiety. 5. SSRIs are the first-line treatment for panic disorder.5-25 mg of sertraline (Zoloft) is used initially. Medication should be combined with cognitive-behavioral therapy for optimal outcome. the initial dose should also be low because of the potential for exacerbating panic symptoms early in treatment. 2. Serotonin-specific reuptake inhibitors and tricyclic antidepressants are most often used. and increased slowly up to100-200 mg per dayas tolerated. Monoamine oxidase inhibitors may be the most efficacious agents available for panic disorder. Buspirone (BuSpar) is not effective for panic disorder. Some patients may require up to 6 mg per day. 1. Treatment of Panic Disorder A.5 mg qid (2 mg/day). benzodiazepines are very effective. B. 6. The average dose is 0.

The person has recognized that the obsessions or compulsions are excessiveor unreasonable. If another psychiatric disorder ispresent. b. leading to marked occupational and social impairment. II. 4.or images experienced as intrusive and causing marked anxiety. The disturbance is not caused by substance abuse or a medical condition. Compulsions a. preoccupation with food in an eating disorder. 2. d. 5. or images arenot limitedtoexcessive worries about real problems. Specify if the patient has poor insight into his illness. orattempts to neutralize them with some other thought or action. The person attempts to ignore orsuppresssymptoms. Recurrent. Either Obsessions or Compulsions are present 1. 6. ClinicalFeaturesofObsessive-Compulsive Disorder A. persistent thoughts. or they are clearly excessive. impulses. or significantly interfere with functioning.theperson does notrecognize the symptoms as excessive or unreasonable.Obsessive-Compulsive Disorder (OCD) I. The person recognizes the thoughts. b. Poor insight is present if. The thoughts. Compulsions often occupy a large portion of an individuals day. DSM-IV CriteriaforObsessive-Compulsive Disorder A. These behaviors or mental acts are aimed at preventing distress or preventing a specific dreaded event. c. such as when an individual withobsessionsofcontamination avoids touching anything that might be dirty. B. 3. C. 7. Situations that provoke symptoms are often avoided. for most of the current episode. impulses. The obsessions or compulsions cause marked distress. take more than a hour a day. but they are not connected in a realistic wayto what theyare attempting to prevent. the contentof thesymptoms is not restricted to the disorder (eg. impulses or images as a product of his or her own mind. Obsessions a. Depression is common in patients . Repetitive behaviors or acts that the person feels driven to perform in response to an obsession.

Major Depressive Disorder. There is no sex difference in prevalence. The onset is usually gradual and most patients have a chronic disease course with waxing and waning of symptoms in relation to life stressors. OCDshould notbe diagnosed if symptoms are caused by another psychiatric condition (eg.with OCD.Patients withschizophrenia mayhave obsessivethoughtsorcompulsive behaviors. schizophrenia . C. Specific or Social Phobia. In GAD. E. IV. and these children may not consider their behavior tobe unreasonable or excessive. Schizophrenia. however. however. Generalized Anxiety Disorder. These obsessive thoughts are usually not associated with compulsive behaviors and are accompanied by other symptoms of depression. hair pulling intrichotillomania). B. D. Up to 50% of patients with Tourette's disorder have coexisting OCD. E. Patients are reluctanttodiscuss symptoms. obsessions usually do not involve real life situations. but the age of onset is earlier in males. Washing and checking rituals are common in children with OCD. however. obsessive rumination about finances or a relationship). Alcohol or sedative-hypnotic drug abuse is common in patients with OCD because they attempt to use the drug to reduce distress. obsessive worries are about real life situations. D. The concordance rate for monozygotic twins is markedly higher compared to dizygotic twins. The lifetime prevalence of OCD is approximately 2. Body DysmorphicDisorderorTrichotillomania. III.DifferentialDiagnosisofObsessive-Compulsive Disorder A. cocaine. in OCD. F. EpidemiologyofObsessive-Compulsive Disorder A. butitmayoccasionally begin in childhood. Major depression may be associated with severe obsessive ruminations (eg. D. caffeine and other symptomatic agents may mimic the anxiety symptoms of OCD. Amphetamines. leading to an underdiagnosis of OCD. C. Fifteen percent of patients have a chronic debilitating course with marked impairment in social and occupational functioning. only5%ofOCD patients have Tourette's disorder.5%. behaviors or impulses mayoccur in these disorders. Substance-Induced AnxietyDisorder or AnxietyDisorderDue to a Medical Condition. On rare occasions a brain tumor or temporal lobe epilepsy can manifest with OCD symptoms. B. OCD usually begins in adolescence or earlyadulthood. E. Recurrent thoughts.

and control. Individuals with OCPDare preoccupied withperfectionism. 5. 3. The duration of symptoms is at least six months. paroxetine (Paxil) 40-60 mg. or sertraline (Zoloft) 200 mg. The individual often fears that he will act in a way that will be humiliating or embarrassing. anxious anticipation. The avoidance. Treatment of Obsessive-Compulsive Disorder A. which may take the form of a panic attack. The feared situations are avoided or endured with intense distress. 9. DSM-IV Diagnostic Criteria for Social Phobia 1. 7. They do not exhibit obsessions or compulsions. . desensitization or flooding. buthighdosesofSSRIsmaybe required. sertraline (Zoloft). F. mayalso be effective. 6. V. Behavior therapy. citalopram (Celexa) and fluvoxamine (Luvox) are effective. D. A marked and persistent fear of social or performance situations in which the person is exposed to unfamiliar people or to scrutiny by others. paroxetine (Paxil) fluoxetine (Prozac).is associated with frank hallucinations and delusions. such as thought stopping. Social Phobia I. The fear is notcaused bya substance or medical condition and is not caused by another disorder. such as fluoxetine (Prozac) 60-80 mg. 4. Clomipramine (Anafranil). Specify if the fear is generalized: The fear is generalized if the patient fears most social situations. and they do not believe that their behavior is abnormal. Standard antidepressant doses of clomipramine are usually effective. Obsessive-Compulsive Personality Disorder (OCPD). or distress in the feared situations interferes with normal functioning or causes marked distress.Oftena combination of behavioral therapy and medication is most effective. The person recognizes that the fear is excessive or unreasonable. 2. If a medical condition or another mental disorder is present. Exposure to the feared situation almost invariably provokes anxiety. B. the fear is unrelated (eg. the fear is not of trembling in a patient with Parkinson's disease). order. Pharmacotherapy is almost always indicated. C. 8.

Social phobia is more frequent (up to tenfold) in first-degree relatives of patients with generalized social phobia. low self-esteem. with a childhood history of shyness. For example. The effective dosage can be very low. B. cocaine. Substances suchascaffeine. SSRIs. Benzodiazepines. or writing in public. Substance-Induced AnxietyDisorder. such as propranolol. D. Obsessive-Compulsive Disorder. Clinical Features of Social Phobia A. The diagnosis of social phobia should be made only if the anxiety is unrelated to another disorder.Differential Diagnosis of Social Phobia A. or of using a public restroom. Excessive social worry and anxiety can occur in manymood and psychotic disorders. Most patients with social phobia fear public speaking. orAnorexia Nervosa. then social phobia should not be diagnosed. B. difficulty being assertive. Less common fears include fear of eating. Lifetime prevalence is 3-13%.5 ­ 2 mg per day. Social phobia is often a lifelong problem. while less than half fear meeting newpeople. C. such as 10-20 mg . alcohol or benzodiazepines may cause a withdrawal syndrome that can mimic symptoms of social phobia B. Hyperthyroidism and other medical conditions may produce significant anxiety. Patients often display hypersensitivity to criticism. C.Anxietysymptoms are common in depression and the anxiety disorders. Onset usually occurs in adolescence.are the first-linemedication for social phobia. C. V. B. Epidemiology and Etiology of Social Phobia A. may be used if SSRIs are ineffective. Mood and Psychotic Disorders. IV. such as paroxetine (Paxil) 20-40 mg/day or sertraline (Zoloft) 50-100 mg/day. and should be ruled out.II. Social phobia with performance anxiety responds well to beta-blockers. Avoidance of speaking in front of groups may lead to work or school difficulties. drinking. Anxiety Disorder Due to a General Medical Condition. social phobia should not be diagnosed in panic disorder if the patienthas social restriction and excessive anxiety about having an attack in public. D. and inadequate social skills. Hypochondriasis. Specific Phobia. such as clonazepam (Klonopin) 0. If anxiety occurs only during the course of the mood or psychotic disorder. but the disorder may remit or improve in adulthood.amphetamines. III. Treatment of Social Phobia A.

which may take the form of a panic attack. airplanes. II. dogs). D. storms. The avoidance.qid. water). Symptoms are not caused by another mental disorder (eg. Phobias that continue into adulthood rarely remit. Specific Phobia I. anxious anticipation. vomiting). B. It may also be used on a prn basis. elevators. H. E. Natural Environmental (eg. Situational (eg. 5. 3. fear of dirt in someone with OCD). Recognition by the patient that the fear is excessive or unreasonable. 20-40 mg given 30-60 minutes prior to the anxiety provoking event. Cognitive/behavioral therapies are effective and should focus on cognitive retraining. situations that may lead to choking. the duration must be at least six months. Most childhood phobias are self-limited and do not require treatment. C. Specify Types of Phobias 1. B. G. Age of onset is variable. Animal (eg. 4. F. III. B. that is caused by the presence or anticipation of a specific object or situation. Most do not cause clinically significant impairment or distress. Exposure tothe feared stimulus provokes an immediate anxiety response. D. In individuals under age 18. Other (eg. C. The lifetime prevalence of phobias is 10%. Vasovagal fainting is seen in 75% of patients with blood-injection injury phobias. Epidemiology of Specific Phobia A. Specific phobias often occur along with other anxiety disorders. Fear of animals and other objects is common in childhood. and females with the disorder far outnumber males. enclosed places).and relaxation techniques. such as unwillingness to go to school. 2. Combined pharmacotherapy and cognitive or behavioral therapies is the most effective treatment. or distress in the feared situations interferes with functioning or causes marked distress. Blood-injection injury. and specific phobia is not diagnosed unless the fear leads to significant impairment. Clinical Features of Specific Phobia A.desensitization. heights. C. Marked and persistent fear that is excessive or unreasonable. The phobic situation is avoided or endured with intense anxiety. Specific phobias mayresultin a significant restriction of life-activities or occupation. DSM-IV Diagnostic Criteria A. .

restricted affect. Treatment of Specific Phobia A. DSM-IVDiagnostic CriteriaforPost-Traumatic Stress Disorder A. consisting of gradually increasing exposure to the feared situation. Manypsychiatric disorders present with marked anxiety.IV. amnesia. For example. whichis characterized bypoor concentration. specific phobia should not be diagnosed in panic disorder if the patient merely has excessive anxiety about having a panic attack. Excessive worry and anxiety occurs in many mood and psychotic disorders. D. The patient persistently reexperiences the event through intrusive recollection or nightmares. Post-Traumatic Stress Disorder I. B. If anxiety occurs only during the course of the mood or psychotic disorder. Alcohol or benzodiazepine withdrawal can also mimic phobic symptoms. then specific phobia should not be diagnosed. C. E. B. A commonly used technique is systemic desensitization.Differential Diagnosis of Specific Phobia A. combined with a relaxation technique such as deep breathing. Anxiety Disorder Due to a General Medical Condition. C. V. Substancessuchascaffeine. or intense distress when exposed to reminders of the event. The patient may have feelings of detachment (emotional numbing). and the diagnosis of specific phobia should be made only if the anxiety is unrelated to another disorder. Substance-Induced AnxietyDisorder. Mood and Psychotic Disorders.SocialPhobia. A general state of increased arousal persists after the traumatic event.Hypochondriasis or Anorexia Nervosa. Post-traumatic stress disorder (PTSD) occurs after an individual has been exposed to a traumatic event that is associated with intense fear or horror.amphetamines and cocaine can mimic phobic symptoms. insomnia. hypervigilance. exaggerated startle response. anhedonia. Beta-blockers may also be useful prior to confronting the specific feared situation. Hyperthyroidism and other medical conditions may produce significant anxiety. Symptoms have been present for .Obsessive-Compulsive Disorder. reliving of the experience (flashbacks). or irritability (two required). The primary treatment is behavioral therapy. Panic Disorder. B. or active avoidance of thoughts or activities that may be reminders of the trauma (three required). D.

aggression. substance abuse. and suicide are increased. Symptoms have been present for less than three months. A stressful event may be associated with the onset of depression. Personality change. B. often were present before the traumatic event. II. Differential Diagnosis of Post-Traumatic Stress Disorder A. Obsessive-Compulsive Disorder. numbing. PTSD maybe an illness for which monetary compensation is given. Anxiety Disorders. IV. With Delayed Onset. F.somatization disorder. and perceptual disturbances may occur.dissociativesymptoms. poor impulse control. Individuals with a personal history of maladaptive responses to stress may be predisposed to developing PTSD. and avoidance. Symptoms begin six months after the stressor. and the ideas are not usually recollections of past events. B. Borderline Personality Disorder can be associated with anhedonia. Chronic. The risk of depression. Symptoms. these ideas lack a relationship to a specific traumatic event. Symptoms cause significant distress or impaired occupational or social functioning. However. III. Depression is also associated with insomnia. Acute.poor concentration. anhedonia. C. The presence of a primary financial gain for which patients may fabricate or exaggerate symptoms should be considered during evaluation. poor concentration.other anxietydisorders. EpidemiologyofPost-Traumatic Stress Disorder A. however. E. Clinical Features of Post-Traumatic Stress Disorder A. C. B. Survivor guilt (guilt over surviving when othershavedied)maybeexperienced if the trauma was associated with a loss of life. OCD is associated with recurrent intrusive ideas. V. Depression is notcommonlyassociated withnightmares or flashbacks of a traumatic event. Other features of BPD such as avoidance . The prevalence in combat soldiers and assault victims is 60%. Malingering. C.at least one month. D. C.Symptomshave been present for greater than three months.Classification of Post-Traumatic Stress Disorder A. and feelings of detachment. B. Other anxiety disorders can cause symptoms of increased arousal. past history of emotional trauma and dissociative states similar to flashbacks. The lifetime prevalence of PTSD is 8% and is highest in young adults.

acute phase of the illness. lithium. insomnia. hypervigilance. The patient mayhave feelings of detachment. Symptoms occur within one month of a stressor and last between two days and four weeks. accident). anticonvulsants. especially for symptoms of increased arousal. and impulsivity distinguishes BPD from PTSD. B. D. and MAO inhibitors) are moderately effective. Sertraline (Zoloft) and paroxetine (Paxil) have demonstrated efficacy for all the symptom clusters of PTSD. reliving of the experience (flashbacks). or intense distress when exposed to reminders of the event. A general state of increased arousal persists after the traumatic event. amitriptyline.Benzodiazepines are not been effective for PTSD. DSM-IVCriteriaforAcute Stress Disorder. amnesia. anhedonia. intrusive thoughts. Older antidepressants (imipramine. exaggerated startle response. C. support groups. Treatment at higher doses than are used for depression may be required. Propranolol. 2. B.Treatment of Post-Traumatic Stress Disorder A. VI. and buspirone may be effective and should be considered if there is no responsetoantidepressants. E. and coexisting depression. natural disaster. C. whichischaracterizedbypoor concentration. and family therapy are effective adjuncts to pharmacological treatment. A.of abandonment. I. Symptoms described below occur after an individual has been exposed to a traumatic event that is outside the realm of normal human experience (combat. The individual has three or more . The patient persistentlyreexperiences the event through intrusive recollection or nightmares. or active avoidance of thoughts or activities that may be reminders of the trauma (three required). Acute Stress Disorder Acute stress disorder may occur as an acute reaction following exposure to extreme stress. behavioral therapy. Other SSRIs are also likely to be effective. identity disturbance. restricted affect. except during the early. or irritability (two required). Persistent avoidance of the traumatic event and emotional numbing (feeling of detachment from others) may be present. physical assault. Additional findings in acute stress disorder may include the following: 1. Psychotherapy.

d. C. B. . Treatment of Acute Stress Disorder A. II. Treatment of acute stress disorder consists of supportive psychotherapy. b. Sedative hypnotics are indicated for short-term treatment of insomnia and symptoms of increased arousal. The presence of acute stress disorder mayprecede PTSD. Depersonalization. see page 121. c.ofthe following dissociativesymptoms: a. Antidepressantmedications are indicated if these agents are ineffective. Derealization. Dissociative amnesia.The clinical approach to acute stress disorder is similar to PTSD. e. References References. Reductioninawarenessofsurroundings. Subjective sense of numbing. detachmentorabsence ofemotional responsiveness.

pervasive and maladaptive to the point where they cause significant social or occupational dysfunction or subjective distress. or a medical condition. Patterns of behavior and perception cannot be caused by stress. Patients with cluster A personality disorders often develop schizophrenia. . another mental disorder. A personality disorder is diagnosed when personalitytraitsbecome inflexible. DSM-IV Diagnostic Criteria of Paranoid Personality Disorder A. and is quick toreactangrilyor tocounterattack. and is manifested by at least four of the following: 1. other people and oneself. B. personality disorders are not generally diagnosed in children. The patient suspects others are exploiting. beginning by early adulthood. 3.Personality Disorders I. The patientpersistentlybears grudges. Paranoid Personality Disorder I. 2. A pervasive distrust and suspiciousness of others is present without justification. or deceiving him. Cluster A Personality Disorders Paranoid. Patients with these disorders have a preference for social isolation. Theyareconsideredpartoftheschizophrenia-spectrum disorders. Patients usually have little or no insight into their disorder. The patient fears that information given to others will be used maliciously against him. harming. Therefore. General Characteristics of Personality Disorders A. 4. Personality traits consist of enduring patterns of perceiving. schizotypal and schizoid personality disorders are referred to as cluster Apersonality disorders. 6. There is also an increased incidence schizophrenia in first-degree compared to the general population. The patient repeatedly questions the fidelity of his spouse or sexual partner. The patient perceives attacks that are not apparent to others. relating to. Benign remarks by others or benign events are interpreted as having demeaning or threatening meanings. 5. 7. C. drug or medication effect. possiblymilder variants ofschizophrenia. D. Personality patterns must be stable and date back to adolescence or early adulthood. The patient doubts the loyalty or trustworthiness of others. and thinking about the environment.

Delusional Disorder. but establishing and maintaining the trust of patients may be difficult because these patients have great difficulty tolerating intimacy. Symptoms of anxiety and agitation may be severe enough to warrant treatment with anti-anxiety agents. The patient has little interest in having sexual experiences. C. Treatment of Paranoid Personality Disorder A. C. C.Acute symptoms are temporally related to a medication. including family relationships. Schizoid Personality Disorder I. Low doses of antipsychotics are useful for delusional accusations and agitation. Paranoid Schizophrenia. C. 3. The patient takes pleasure in few activities.Differential Diagnosis of Paranoid Personality Disorder A. III. The patient is often hypervigilant and constantly looking for proof to support his paranoia. The patient chooses solitaryactivities. The patient neither desires nor enjoys close relationships. The disorderis more common in first-degree relatives of schizophrenics compared to the general population. Epidemiologyof Paranoid Personality Disorder A. B. Patients are often argumentative and hostile. 4. The longstanding patterns of behavior required for a personality disorder are not present. 5. IV. The disorder is more common in men than women. B. Patients with the disorder may develop schizophrenia.II.Hallucinations and formal thought disorder are not seen in personality disorder. ClinicalFeatures of Paranoid Personality Disorder A. Patients are quick to counterattack and are frequently involved in legal disputes. B. B. beginning by early adulthood and indicated by at least four of the following: 1. These patients rarely seek treatment.Pathological jealousyis common. Psychotherapy is the treatment of choice for PPD. Apervasive pattern of social detachment with restricted affect. DSM-IV Diagnostic Criteria for Schizoid Personality Disorder A. The patient has no close friends . Fixed delusions are not seen in personality disorders. drugs or a medical condition. 2. Patients have a high need for control and autonomy in relationships to avoid betrayal and the need to trust others. PersonalityChange Due to a General MedicalConditionandSubstance-Related Disorder. V.

and these patients generally do notmarryunless pursued aggressively by another person. Thepatientdisplaysemotional detachment or diminished affectiveresponsiveness. and is uninvolved in the everyday concerns of others. C. . V. Schizophrenia. 7. behavior and speech are not seen in schizoid personality disorder. The patient is indifferent to the praise or criticism of others. whereas schizophrenic patients usually have poor work histories. Patients with SPD are often emotionally blunted. which is thought to be more common in men than women. drugs or a medical condition.or confidants except first-degree relatives. Paranoid patients are able to express strong emotion when theyfeel persecuted. PersonalityChange Due to a General MedicalConditionandSubstance-Related Disorder. Patients with schizoid personality disorder mayhave good work histories.antipsychotics andpsychostimulants has been described without consistent results. Avoidant Personality Disorder. Schizoid Personality Disorder is a rare disorder. E. The use ofantidepressants. C. Hallucinations and formal thought disorder are not seen in personality disorders. Schizoid Personality Disorder is more common in first-degree relatives of schizophrenics compared to the general public. Individual psychotherapyis the treatment ofchoice. B. Schizotypal Personality Disorder. Patients with Schizoid Personality Disorder may develop schizophrenia. III.Grouptherapyisnotrecommended because other patients will find the patient's silence difficult to tolerate. Clinical Features of Schizoid Personality Disorder A.Acutesymptoms are temporally related to a medication. B. B. Paranoid Personality Disorder. These patients are able to work if the job allows for social isolation. II. Epidemiologyof Schizoid Personality Disorder A. The patient often appears cold and aloof. Treatment of Schizoid Personality Disorder A. The longstanding patterns of behavior required for a personality disorder are not present. Social isolation is subjectivelyunpleasant for avoidant patients. Unlike schizoid patients.avoidantpatients are hypersensitive to the thoughts and feelings of others. 6. Eccentricities and oddities of perception. B.Differential Diagnosis of Schizoid Personality Disorder A. Schizoid patients are not able to express strong emotion. IV. D. C.

it is of brief duration. This disorder is more common in relatives of schizophrenics compared to the general population. belief thata television program is really about him). 8. Behavior or appearance that is odd. IV. B.” illusions and derealization are common.Schizotypal Personality Disorder I. and inappropriate behavior may occur. Excessive social anxiety that does not diminish with familiarity. Schizoid and Avoidant Personality Disorder. These patients often displaypeculiarities in thinking. Ideasofreference:interpreting unrelated events as having direct reference to the patient (eg. . A pervasive pattern of discomfort with and reduced capacity for close relationships as well as perceptual distortions and eccentricities of behavior. F. III. telepathy or a “sixth sense”). C. Lack of close friends other than first-degree relatives. Inappropriate or constricted affect. including bodily illusions. C. Schizoid and avoidant patients will not display the oddities ofbehavior.belief in “extra sensory perception. 9. These patients may seek treatment for anxiety or depression.Differential Diagnosis of Schizotypal Personality Disorder A. behavior andcommunication. E. G. The patient may have a vivid fantasy life with imaginary relationships. B.superstitiousness. Odd beliefsor magicalthinkinginconsistent withculturalnorms (eg. At least five of the following should be present: 1. ClinicalFeatures of Schizotypal Personality Disorder A. B. Unusual perceptual experiences. beginning by early adulthood.perception. belief in clairvoyance. 7. Suspiciousness or paranoid ideation. 2. Patients with schizotypal personality disorder may develop schizophrenia. 3. Speech may be idiosyncratic.circumstantial. II. Oddthinkingandspeech(eg. Repeated exposure will not decrease social anxiety since it is based on l paranoidconcernsandnotonsef-consciousness. Magical thinking. metaphorical. DSM-IV Diagnostic Criteria A.and communication of schizotypal patients. No formal thought disorder is present in personality disorders. or stereotyped thinking) 5. The prevalence is approximately 3% in the general population. EpidemiologyofSchizotypalPersonality Disorder A. 6. When psychosis is present in schizotypal patients. D. Schizophrenia. eccentric or peculiar. such as the use of unusual terminology. Discomfort in social situations. 4.

Acute symptoms are temporally related to a medication.C. PersonalityChange Due to a General MedicalConditionandSubstance-Related Disorder. Patients with paranoid personality disorder will not display the oddities ofbehavior. drugs or a medical condition. V. Psychotherapy is the treatment of choice for schizotypal personality disorder. . B.perception and communication ofschizotypal patients. The longstanding patterns of behavior required for a personality disorder are not present. Antipsychotics maybe helpful in dealing with low-grade psychotic symptoms or paranoid delusions. Treatment of Schizotypal Personality Disorder A. paranoid patients can be very verbally aggressive and do not avoid conflict. D. Unlikeschizotypals. Antidepressants may be useful if the patient also meets criteria for a mood disorder. Paranoid Personality Disorder.

3. These disorders are characterized by dramatic or irrational behavior. indicated by at least three of the following: 1. substance abuse. but they are also capable of great superficial charm. Aggression to people and animals. This diagnosis is limited to the presence of illegal behavior only. 3. APD is more common in first-degree relatives of those with the disorder.Cluster B Personality Disorders Antisocial. IV. Since age 15 years. C. Consistent irresponsibility: repeated failure to sustain consistent work or honor financial obligations. fraud. Interactions with others are typically exploitative or abusive. Destruction of property. DSM-IV Diagnostic Criteria for Antisocial Personality Disorder A.Differential Diagnosis of Antisocial Personality Disorder A. II. III. 5. Epidemiologyof Antisocial Personality Disorder A. B. ClinicalFeatures of AntisocialPersonality Disorder A. such as repeated physical fighting or assaults. 2. Antisocial PersonalityDisorder I. Deceitfulness or theft. Lack of remorse for any of the above behavior. These patients do not have a capacity for empathy. 4. D. Serious violation of rules. Deceitfulness: repeated lying or “conning” others for profit or pleasure. fighting. Failure to conform to social norms by repeatedly engaging in unlawful activity.Substance . Lying. B. 4. Impulsivity or failure to plan ahead. Adult Antisocial Behavior. B. 6. A historyof some symptoms of conduct disorder before age 15 years as indicated by: 1. physical abuse. B. 2. 7. Patients may be arrogant. Substance-Related Disorder. borderline. the patient has exhibited disregard for and violation of the rights of others. and drunk driving are common. Irritability and aggressiveness. long-term patterns required for a personality disorder. Reckless disregard for the safety of self or others. The male-to-female ratio is 3:1. These patients tend to be very disruptive in clinical settings. histrionic and narcissistic personality disorders are referred to as cluster B personalitydisorders. Patients with adult antisocial behavior do not show the pervasive. stealing.

Narcissistic Personality Disorder.Antidepressants can be helpful if depression or an anxiety disorder is present. Unstable and intense interpersonal relationships. reckless driving. and because enhanced peer interaction minimizes authority issues. binge eating). The manipulativeness of borderline patients is aimed at getting emotional gratification rather than aimed at financial motivations. These patients are also impulsive and manipulative.spending. DSM-IV Diagnostic Criteria for Borderline Personality Disorder Apervasivepattern ofunstable interpersonal relationships. and beta-blockers have been used for impulse control problems. including rage reactions. V. 5. Identity disturbance: unstable self-image or sense of self. gestures or threats. Recurrent suicidal behavior. intense anger . Impulsivity in at least two areas that are potentiallyself-damaging (eg. Inappropriate. but they are not as aggressive or deceitful as antisocial patients. irritability or anxiety of short duration). Narcissistic patients also lack empathy and are exploitative. promiscuity. D. Borderline Personality Disorder I. 4. Borderline Personality Disorder. 6. unstable self-image.Aniconvulsants. Inpatient self-help groups are the most useful treatment because the patient is not allowed to leave. Many patients will meet criteria for both diagnoses.beginning by early adulthood. Chronic feelings of emptiness. but they are more emotionally unstable and they are less aggressive. 3. 7. B. and crimes may be committed to obtain drugs or to obtain money for drugs. C. These patients will try to destroy or avoid the therapeutic relationship.substance abuse. lithium.abuse iscommon inantisocialpersonality disorder.unstable affects. Psychotropic medication is used in patients whose symptoms interfere with functioning or who meet criteria t foranotherpsychiatricdisorder. Frantic efforts to avoid real or imagined abandonment.orself-mutilating behavior. alternating between extremes of idealization and devaluation. and poor impulse control. 8. sudden intense dysphoria. 2. Treatment of Antisocial Personality Disorder A. Affective instability (eg. and indicated by at least five of the following: 1.

Pharmacotherapy is frequently used for coexisting mood disorders. stress-related paranoid ideation. The clinical presentation of BPD is highly variable. Dependent Personality Disorder. Histrionic Personality Disorder. C. III. IV. ClinicalFeaturesofBorderlinePersonality Disorder A. or a medical condition. resistance to treatment. B. The prevalence is 1-2%. Patients frequently try to recreate their personal chaos in treatment by displaying acting-out behavior. 9. The female-to-male ratio is 2:1. Differential Diagnosis of Borderline Personality Disorder A. C. Chronic dysphoria is common. and anxiety disorders. drugs. Treatment of Borderline Personality Disorder A. The disorderisfivetimes more common in first-degree relatives. Normal adolescence with identitydisturbance and emotional lability shares many of the same characteristics of BPD. however. Chaotic interpersonal relationships are characteristic. These patients are also manipulative and attention seeking. Acute symptoms are temporally related to medications. but they do not display self-destructiveness and rage. B. Psychotherapy is the treatment of choice.II. C. B. but the disorder occurs in 30-60%ofpsychiatric patients. PersonalityChange Due toaGeneral MedicalConditionandSubstance-Related Disorder. the longstanding pervasive pattern of behavior required for a personality disorder is not present. B. . Valproate (Depakote) or SSRIs maybe helpful for impulsive-aggressive behavior. Transient. and self-destructive orself-mutilatorybehavior is common. or difficulty controlling anger. labilityof mood and affect. dependent patients will increase their submissive behavior rather than display rage as do borderline patients. Suicide threats and attempts are common. eating disorders.and regression. Achildhood historyof abuse or parental neglect is common. Adolescence. D. Epidemiologyof Borderline Personality Disorder A. V.anddesperate dependence on others is caused by inability to tolerate being alone. or severe dissociative symptoms. When faced with abandonment. Psychosis and dissociation are not typically seen in histrionic patients.

EpidemiologyofHistrionic Personality Disorder A. 2. C. The patient is bored with routine and dislikes delays in gratification. beginning by early adulthood.Histrionic Personality Disorder I. superficially charming. .and exaggerated expression of emotion is used. B. 8. The prevalence of HPD is 2-3%. III. impulsive. 5. superficiallycharming. Histrionic patients are dramatic and theatrical but typically lack histories of antisocial behavior. 6. The patient may resort to suicidal gestures and threats to get attention. Histrionic personality disorder is much more common in women than men. and manipulative. C. but does notfinish them (including relationships). t t impulsive. These patients have higher rates of depression. Dramatic emotional “performances” of the patient appear to lack sincerity. The patient is easily influenced by others or by circumstances. transient psychosis. or dependency. DSM-IV Diagnostic Criteria A. 3. The patient is not comfortable unless he is the center of attention. and manipulative. Dramatic. The patient begins projects. A pervasive pattern of excessive emotionality and attention seeking. D. somatization and conversion disorder compared to the general population. Relationships are considered to be more intimate than they are in reality. E. Anisocialpatientsarealsosensaion-seeking. Some patients meet criteria for both BPD and HPD. and dissociation which are not seen in histrionic patients. These patients often attempt to control relationshipswithseduction. Speechisexcessivelyimpressionistic and lacking in detail. 4. Borderline Personality Disorder 1. ClinicalFeatures of Histrionic Personality Disorder A. Differential Diagnosis of Histrionic Personality Disorder A.theatrical. While patients with Borderline Personalitycanalsobesensation-seeking. 2. 2. Rapidlyshifting and shallowexpression of emotions are present. B. 7. II. B. IV. Antisocial Personality Disorder 1. as indicated byfive or more ofthe following: 1. The patient is often inappropriately sexually seductive or provocative with others.manipulation. The patient consistently uses physical appearance to attract attention. they also have identity disturbance.

C. DSM-IV Diagnostic Criteria A. expecting others to meet their needs immediately. Keeping patients in therapycan be challenging since these patients dislike routine. Narcissists also seek constant attention. drugs. haughtybehavior or attitudes. A pervasive pattern of grandiosity (in fantasy or behavior). The patient is often envious of others or believes that others are envious of him. Narcissistic patients only pursue relationships that will benefit them in some way. Anexaggeratedsenseofself-importance. II. Takes advantage of others to achieve his own ends. B. The disorder begins byearlyadulthood and is indicated by at least five of the following: 1. or ideal love. and they can become quite indignant ifthis does not happen.Acute symptoms are temporaly related to medication. Patients with narcissistic personality disorder exaggerate their achievements and talents. Treatment of Histrionic Personality Disorder A. brilliance. D. C. 3. Lacks empathy. Antidepressants are used ifdepression is also present. Narcissistic Personality Disorder 1. power. Insight-oriented psychotherapy is the treatment of choice. These patients feel very entitled. V. 9. 2. but it must be positive in order to confirm grandiosity and superiority. 5. other special or high-status people (or institutions). or should associate with. Narcissistic Personality Disorder I. Requires excessive admiration. and lack of empathy. B. 4. Believes he is “special” and can only be understood by. Histrionics are less selective and will readily appear weak and dependent in order to get attention. Shows arrogant. Has a sense of entitlement. 6. need for admiration. beauty. PersonalityChange DuetoaGeneral MedicalConditionandSubstance-Related l Disorder. and they are surprised when theydo not receive the recognition they expect. These patients are self-absorbed . 8. ClinicalFeatures of NarcissisticPersonality Disorder A. 7. Their inflated sense of self results in a devaluation of others and their accomplishments. 2. or a medical condition. Preoccupation with fantasies of unlimited success.

EpidemiologyofNarcissisticPersonality Disorder A. B. Interpersonal exploitation. Histrionic patients are also attention seeking. Coexisting substance abuse may complicate treatment. and lack of empathy can be seen in both antisocial personality disorder and narcissistic personality disorder. Antisocial Personality Disorder. The prevalence of NPD is less than 1% in the general population and up to 16% in clinical populations.butthe therapeutic relationship can be difficult since envy often becomes an issue. Borderline Personality Disorder. antisocial patients do not require constant admiration nor do they display the envy seen in narcissistic patients. B.therefore. and these patients can react with rage. Much of narcissistic behavior serves as a defense against very poor self-esteem. Any perception of criticism is poorly tolerated. Psychotherapy is the treatment of choice. but the attention they seek does not need to be admiring. Differential Diagnosis of Narcissistic Personality Disorder A. PersonalityChangeDuetoaGeneral MedicalConditionandSubstance-Related Disorder. antidepressants are useful for adjunctive therapy. The disorder is more common in men than women. B. Studies have shown a steadyincrease in the incidence of narcissistic personality disorder. These patients also tend to idealize and devalue others. V.and unable to respond to the needs of others. self-destructivebehavior.All symptoms are temporally related to medication. They aremorehighlyemotional and seductive compared to patients with NPD. IV. but narcissistic patients lack the unstable identity. Histrionic Personality Disorder. However. drugs or a medical condition. III. Depression frequentlycoexists with NPD. C. D. skill or belongings that they do not possess. Treatment of Narcissistic Personality Disorder A. These patients are very prone to envyanyone who possesses knowledge.andabandonment fears that characterize borderline patients. superficial charm. D. .

Opportunities to supervise others at work are usually avoided by the patient. III. Patients may meet criteria for both disorders. Avoidant Personality Disorder I. Clinical Features of Avoidant Personality Disorder A. disapproval or rejection. avoidant personality disorder patients usually long to be accepted and be more social. 7. The patient views himself as socially inept. IV. feelings of inadequacyand hypersensitivity. Despite self-imposed restrictions. Generalized Type shares many features of avoidant personality disorder. B. Restrained in intimate relationships due to fear of being shamed or ridiculed. Differential Diagnosis of Avoidant Personality Disorder A. The patient is usually shy and quiet and prefers to be alone. Reluctance to take personal risks or to engage in new activities because theymaybe embarrassing. These patients tend to be anxious and their personality pathology is a maladaptive attempt to control anxiety. These patients are often devastated by minor comments they perceive to be critical. 5. B. beginning byearlyadulthood. Social Phobia. 2. The patient avoids occupational activities withsignificantinterpersonal contact due to fear of criticism. 3. II. Epidemiologyof Avoidant Personality Disorder A. dependent and obsessive-compulsive personality disorders are referred to as cluster C personalitydisorders. Preoccupied with being criticized or rejected in social situations. unappealing or inferior to others. DSM-IV Diagnostic Criteria A pervasive pattern of social inhibition. and indicated by at least four of the following: 1.Cluster C Personality Disorders Avoidant. 6. childhood shyness is notapredisposing factor. The male-to-female ratio is 1:1. The patient usually anticipates unwarranted rejection before it happens. Unwilling to get involved with people unless certain of being liked. 4. Although adultswithavoidantpersonality disorder were frequentlyshyas children. The two disorders mayonlybe differentiated by a life-long pattern of avoidance seen in patients with avoidantpersonality . C. Inhibited in new interpersonal situations due tofeelings ofinadequacy.

Individual psychotherapy. Goes to excessive lengths to obtain nurturance and support. 5. V. Dependent Personality Disorder. Group therapy may assist in dealing with social anxiety. Beta-blockers can be useful for situational anxiety. however. and fears of separation beginning byearlyadulthood and indicated by at least five of the following: 1. Since many of these patients will meetcriteria forSocialPhobia (generalized). D. Dependent Personality Disorder I. Behavioral techniques. such as assertiveness training and systematic desensitization.disorder. Patients may meet the criteria for both disorders. but they will risk humiliation and rejection in order to get theirdependent needs met. Panic Disorder with Agoraphobia. C. Needsotherstoassumeresponsibility for major areas of his life. 3. Avoidant patients recognize that social isolation is abnormal. Difficultyexpressing disagreement with others and unrealistically fears loss of support or approval if he disagrees. Patients are prone to other mood and anxiety disorders. B. In patients with panic disorder with agoraphobia. DSM-IV Diagnostic Criteria A pervasive and excessive need to be cared for. . Difficulty initiating projects or doing things on his or her own because of a lack ofself-confidence in judgment or abilities. and the avoidanceisaimed atpreventing another panic attack from occurring. These patients are also hypersensitive to criticism and crave acceptance. 4. clinging behavior. schizoid patients do not fear criticism and rejection. These patients also avoid interactions with others and are anxious in social settings. and these disorders should be treated with antidepressants or anxiolytics. avoidance occurs after the panic attack has begun. 2. may help the patient to overcome anxiety and shyness. a trial of SSRI medication mayprove beneficial. C. group psychotherapyand behavioraltechniques may all be useful. Treatment of Avoidant Personality Disorder A. to the point of volunteering to do things that are unpleasant. B. Schizoid Personality Disorder.This need leads tosubmissive. Difficultymaking everydaydecisions without excessive advice and reassurance.

Unrealistically preoccupied with fears of being left to take care of himself. 6. ClinicalFeatures ofDependentPersonality Disorders A. and they have a strong desire for approval. . Dependent patients are at increased risk for mood disorders and anxiety disorders. B. such as assertiveness and social skills training . 8.have all been used with success. Women are affected slightly more than men. group. Histrionic Personality Disorder. Dependent patients react with more submissive behavior when feeling abandoned. III. Some patients may meet criteria for both disorders. Insight-oriented psychotherapy. and behavioral therapies. D.II. Avoidant Personality Disorder: Avoidant patients are more focused on avoiding shame and rejection rather than getting needs met. PersonalityChange Due toa General MedicalConditionandSubstance-Related Disorder:Acute symptoms are temporally related to a medication. drugs or a medical condition. B.Appropriate pharmacological interventions may be used if the patient has these disorders. Borderline Personality Disorder: Borderline patients react with rage and emptinesswhen feeling abandoned. V. These patients may function at work if no initiative is required. Uncomfortable or helpless when alone due to exaggerated fears of being unable to care for himself. These patients are also needy and clinging. EpidemiologyofDependentPersonality Disorders A. but these patients actively pursue almost any kind of attention.Theytend tobeveryflamboyant. Urgently seeks another source of care and support when a close relationship ends. B. Social interaction is usuallylimited to the caretaker network. Treatment of Dependent Personality Disorders A. Differential Diagnosis of Dependent Personality Disorders A. unlike dependent patients. IV. 7. C. Childhood illness or separation anxiety disorder of childhood predispose patients to dependent personality disorder. B. Patients will endure great discomfort in order to perpetuate the caretaking relationship. Family therapy may also be helpful in supporting new needs of the dependent patient in treatment.

even if they have no sentimental value. These patients are often very“frugal” with regard to financial matters. Obsession with detail can paralyze decision making. . 7. These patients prefer logic and intellect to feelings.Obsessive-CompulsivePersonality Disorder I. B. DifferentialDiagnosisofObsessive-Compulsive Personality Disorder A. Tasks may be difficult to complete. ClinicalFeatures ofObsessive-Compulsive Personality Disorder A. V. Miserly spending style toward both self and others.although the two conditions can coexist. Excessively devoted to work and productivity to the exclusion of leisure activities and friendships. rules. 5. Treatment of Obsessive-Compulsive PersonalityDisorder. The male-to-female ratio is 2:1. or a medical condition. to the extent that the major point of the activity is lost. A pervasive pattern of preoccupation with orderliness. Reluctant to delegate tasks to others. The longstanding patterns of behavior required for a personalitydisorder are not present. Obsessive-Compulsive Disorder (OCD). C.scrupulousness t and inflexibility about morality. III. Most patients with OCD do notmeetcriteriaforOCPD. and efficiency. beginning by early adulthood and indicated by at least four of the following: 1. Unable to discard worn-out or worthless objects.Long-term. Obsessive-compulsive personality disorder is more frequent in first­ degree relatives. ethics. PersonalityChange Due to a General MedicalConditionandSubstance-Related Disorder. The prevalence of OCPD is 1% in the general population and up to 10% in clinical populations. organization or schedules. B. 3. 8. IV. Perfectionism interferes with task completion. openness. 4. or values (not accounted for by culture or religion). 2. lists. perfectionism and control. EpidemiologyofObsessive-Compulsive Personality Disorder A. at the expense of flexibility. Therapy can II.Acute symptoms are temporally related to a medication. B. and they are not able to be openly affectionate. Preoccupied with details. C. 6. DSM-IV Diagnostic Criteria A.individual therapy is usually helpful. Overconscieniousness. drugs. Rigidity and stubbornness.

References References. see page 121. .be difficult due to the patient’s limited insight and rigidity.

Medical conditions that present varied symptoms. D. C. History of pain related to at least four sites or functions. anxiety. B. One sexual symptom. resulting in treatment being sought or significant functional impairment.ThefrequencyofSomatization Disorder is inversely related to social class.shortness ofbreath. B. B.Differential Diagnosis of Somatization Disorder A. Symptoms are notintentionallyproduced. Physical Complaints 1.HIVor multiple sclerosis. Prominent somatic complaints can also be associated with depression. Factitious Disorder. II. and hospitalizations. such as systemic lupus erythematosus. III.5%. 2. Malingering is suspected when there are external motives (eg. EpidemiologyofSomatization Disorder A. extremity pain. Onset is before the age of 30.1 to 0. In factitious . D. financial) that would be furthered bythe intentional production of symptoms. Symptoms cannot be explained by organic etiology or symptoms are in excess of what is expected from the medical evaluation. vomiting. surgeries. Fifteen percent of patients have a positive familyhistory. The disorder often begins during adolescence. C. and patients frequently seek medical treatment or pursue multiple concurrenttreatments. 4. Mood and anxietydisorders and substance-related disorders are common in somatization disorder. Somatization disorder is a chronic problem.and theconcordance rate is higher in monozygotic twins. must be excluded. IV. and schizophrenia. Onesymptom suggestiveofa neurological condition (pseudoneurological). The disorder is 5-20 times more prevalent inwomen.and pregnancy or menstruation associated complaints. B. Two-thirds of patients have coexisting psychiatric diagnoses.SomatoformandFactitious Disorders Somatization Disorder I. Frequently encountered symptoms include nausea. Patients undergo multiple procedures. D. 3. Many physical complaints. The lifetime prevalence is 0. The frequencyand severityof symptoms may vary with level of stress. DSM-IV Criteria A. Two GI symptoms. C. Clinical Features of Somatization Disorder A.

urinaryretention. Behaviorally oriented group therapy is also helpful.000 in the general population and in up to 3% of outpatient psychiatric patients. D. IV. F. The physical complaints that occur insomatization disorder are an expression of emotional issues. C. Symptoms are notintentionallyproduced. mutism). B. III. numbness) and motor deficits (paralysis.” Conversion disorder can coexist with depression. and pseudoseizures. C. V. Other symptoms include pseudocyesis (pregnancy). Psychotherapy is beneficial to help the patient find more appropriate and direct ways of expressing their emotional needs.disorder symptoms are intentionally produced to assume the sick role to meet a psychological need. The patient complains of symptoms or deficits affecting voluntary muscles. anxiety disorders. Abnormalities usually do not have a normal anatomical distribution and the neurological exam is normal. The disorder is more common in lower socioeconomic groups. Symptoms are not explained by an organic etiology. The temporal relation of symptoms to a stressful event suggests association of psychological factors. Symptoms result in significant functional impairment. . B. The most common symptoms are sensory (blindness. Conversion Disorder I. Treatment of Somatization Disorder A. Epidemiologyof Conversion Disorder A. Patients often lack the characteristic normal concern about the deficit. or deficits of sensory function that suggest a neurological or medical condition. E. D. Deficits tend to change over time. B. and schizophrenia. ClinicalFeatures of Conversion Disorder A. This characteristic lack of concern has been termed “la belle indifference.Differential Diagnosis of Conversion Disorder A. II. B. torticollis and voluntary motor paralysis (astasia-abasia). Conversion symptoms often will temporarily remit after the disorder has been suggested by the physician. Symptoms are not limited to pain or sexual dysfunction. DSM-IV Criteria for Conversion Disorder A. Conversion disorder occursin1-30/10. The patient should have a primary care physician and should be seen at regular intervals tominimizeinappropriate use of medical services. Medical conditions must be excluded. and are not explained by another mental disorder.

obsessive-compulsive disorder. Hypochondriasis is most frequent between age 20 to 30 years. D. Hypochondriasis I. and panic disorder can often cause prominent somatic complaints with no organic basis. Factitious Disorder. The physician should avoid confrontation or focusing on the symptoms. DSM-IV Criteria for Hypochondriasis A. Repeated diagnostic procedures mayresult in unrelated medical complications. Malingering is characterized by the presence of external motivations behind fabrication of symptoms. Clinical Features of Hypochondriasis A. and there is no sex predominance. C. Despite clinical. and they are intentionally created to assume a sick role. F. Somatization Disorder begins in early life and involves multi-organ symptoms.insight-oriented orbehavioral therapy can facilitate recovery. III. B. The disorder results in significant functional impairment. generalized anxiety disorder. Symptoms are not accounted for by another mental disorder. symptoms are not consciously produced. The patient is not reassured by a negative medical evaluation. C. B. diagnostic or laboratory evaluation. The focus should be on psychological issues and any secondary gain. Symptoms typically last for days to weeks and typicallyremit spontaneously.based on misinterpretation of symptoms. Preoccupation with fear of having a serious disease. Benzodiazepines can be useful when anxiety symptoms are prominent. B. Treatment of Conversion Disorder A. Symptoms are under conscious voluntary control. The prevalence ranges from 4-9%. Major depression. Medical conditions that can produce . II. Supportive. Doctor shopping is common. D. B. Patients tend to be very concerned about symptoms. Anxiolytics and relaxation may also be helpful in some cases. Epidemiology and Classification of Hypochondriasis A. Hypochondriasis “with poor insight” is present if the patient fails to recognize that his concern abouthealth is excessive or unreasonable. E. Duration is greater than six months. B. In conversion disorder. V. IV.DifferentialDiagnosis of Hypochondriasis A. the patient is not reassured.B. Symptoms are not related to delusions or restricted to specific concern about appearance. and complaintsare often vague and ambiguous.

II. B. B.varied symptoms. Factitious Disorder and Malingering. Preoccupation is not caused for by another mental disorder.Concerns are limited onlyto physical appearance. and it may be related to stressful life events. C. Treatment of Hypochondriasis A. There is preliminary evidence that SSRI medications are beneficial. and body build are the most frequently “defective” features. IV. Hypochondriasis is sometimes episodic. Hypochondriacal patients realistically experience the symptoms and do not fabricate them. Concerns about the imagined defect mayreach delusional proportions without meeting criteria for a psychotic disorder. F. BodyDysmorphic Disorder. Improvement usually results from reassurance through regular physician visits. E. D. Conversion Disorder. Major depressive disorder and anxiety disorders frequently coexist with body dysmorphic disorder. C. hair. Familyhistoryreflects a higher incidence of mood disordersand obsessive-compulsive disorder (OCD). and systemic lupus erythematosus. in contrast to the fear of having an illness that occurs in hypochondriasis. ClinicalFeatures of Dysmorphic Disorder A. Facial features. This disorder tends to cause only one symptom. B. The focus of the patient is on the symptoms. A preoccupation with imagined defect in appearance. is most helpful. Epidemiologyof Dysmorphic Disorder A. as opposed to fear of having a disease in hypochondriasis. Multiple visits to surgeons and dermatologists are common. Cognitive-behavioral group therapy. DSM-IV Criteria for Body Dysmorphic Disorder A. and it can be mistaken for dysmorphic disorder. Somatization Disorder. rather than individual therapy. Coexisting psychiatric conditions should be treated. Neurological “neglect” is seen in parietal lobe lesions. The preoccupation causes significant functional impairment. and the patient has less concern about the symptom. III. V. Preoccupation aboutbodyimage are limited toconcerns . with women affected as frequently as men.DifferentialDiagnosis of BodyDysmorphic Disorder A. such as AIDS. B. Anorexia Nervosa. must be excluded. Body Dysmorphic Disorder I. B. The disorder is most common between the ages of 15 and 20 years. multiple sclerosis.

Great effort should be made to confirm the facts presented by the patient and confirm the past medical history. use of drugs such as insulin. More frequent in men and among health-care workers. Classification of Factitious Disorder A.about being “fat. such as a mood disorders. V. SSRI antidepressants and clomipramine are effective. Treatment Bodyof Dysmorphic Disorder. B. Differential Diagnosis A. In this disorder. V. An outside informant should be sought to provide corroborating information. Gender IdentityDisorder. IV. Begins in early adulthood. Patients are able to provide a detailed history and describe symptoms of a particular disease and mayintentionally produce symptoms (eg. III. With combined psychological and physical symptoms. Clinical Features of Factitious Disorder A. Intentional production of physical or psychological symptoms. Surgical repair of the “defect” is rarely successful. Narcissistic Personality Disorder. II.Coexistingpsychiatric conditions. Epidemiology of Factitious Disorder A. concern with a body partis onlyone feature in broad constelation l of other personality features. The patients motivation is to assume the sick role. D. C. DSM-IV Criteria A. Factitious Disorder I. should be treated. With predominantly physical signs andsymptoms(alsoknownasMunchausen Syndrome). . B. Common coexisting psychological symptoms include depression or factitious psychosis.Characterized by discomfort with the patient’s own sex and persistent identification with the opposite sex. Patients with physical symptoms often have histories of many surgeries and hospitalizations. External motives (financial gain) are absent. B. This is considered to be a form of child abuse.” C. Somatoform Disorders: Somatoform disorder patients are less willing to undergo medical procedures. Factitious disorder byproxyischaracterized bythe production of feigning of physical signs or symptoms in another person who is under the person’s care (typically a child). C. Symptomsare notfabricated. C. such as surgery. Identity disturbance and dependent and narcissistic traits are frequent. self-inoculation to produce abscesses). D. B. With predominantly psychological signs and symptoms.

Treatment of Factitious Disorder A. VI. . C.Close collaboration between the medical staff and psychiatrist is recommended.B. No specific treatment exists. B. References References. The condition should be recognized early. Ganser’s syndromerefers toa condition associated with prison inmates who give ridiculous answers to questions (1+ 1= 5)inaneffort toavoid responsibility for their actions. see page 121. Malingering: A recognizable goal for producing symptoms is present. and the prognosis is generally poor.and needless medical procedures should be prevented.

anxiety. Manydrugs can disrupt sleep including beta-blockers. Zaleplon does not cause residual . C. Temporaryuse (less than one month) of short-acting benzodiazepines is especially helpful when there is an identifiable precipitant (eg. except when benzodiazepines are taken with alcohol. Anxiety or depression commonly coexist with insomnia. C. Clinical Features A. decongestants. E. B. D. Treatment A. B. and bronchodilators. Zaleplon does not impair memory or psychomotor functioning on morning awakening. Zolpidem is associated with greater residual impairment in memory and psychomotorperformance than zaleplon. headaches. gastritis. Zolpidem (Ambien) and zaleplon (Sonata) have the advantageofachieving hypnotic effects with less tolerance and less daytime sedation. B.Sleep Disorders Primary Insomnia Primary insomnia is characterized by the inability to initiate or maintain sleep. Differential Diagnosis A. steroids. III. Schizophrenia is associated with fragmented sleep. Zolpidem (Ambien)is a benzodiazepine agonist with a short elimination half-life that is effective in inducing sleep onset and promoting sleep maintenance. substance abuse. thyroid hormones. C. Mood disorders account for less than 50% of insomnia. stimulating antidepressants. The safety profile of benzodiazepines and benzodiazepine receptor agonists is good. calcium channel blockers. mood. I. DSM-IV Criteria A. or psychotic disorders may present with insomnia. death of a loved one). IV. The disorder causes significant distress or impairment in social or occupational functioning. Many medical conditions can cause insomnia including asthma. B. nicotine. lethal overdose is rare. C. drugs of abuse. The disorder is not due to the effects of medication. Difficulty initiating or maintaining sleep when there is no known physical or mental condition (including drug related). peptic ulcer disease. Dyssomnias. or a medical condition. II. resulting in significant distress or impairment. Zaleplon (Sonata) is a benzodiazepine receptor agonist that is rapidlyabsorbed (Tmax = 1 hour) and has a shortelimination half-life of one hour.

or nicotine. Avoid daytime naps. or trazodone (Desyrel). but avoid exercise before sleeping. are common choices. may be effective in promoting sleep onset and sustaining sleep. F. some patients can experience perceptual disturbances Zalepl on (Sonata) 5 -10 mg 1 hour Triazo lam (Halci on) 0. such as flurazepam (Dalmane). resulting in daytime sedation or functional impairment. alcohol. Allow for a period of relaxation before bedtime (hot bath). Amitriptyline (Elavil). Encourage patient to keep a consistent pattern of waking. It can be used at bedtime or after the patient has tried to fall asleep naturally. Engage in regular exercise. G. and sleeping at the same time each day.25 mg qhs 2 hours . Discontinue stimulant caffeine. 50-100 mg. 2. no daytime hangover Nonbenzodiazepine . These drugs tend to accumulate and have effects that extend beyond the desired sleep period. 3. 5. Sedating antidepressantsare sometimes used as analternativetobenzodiazepines or benzodiazepine receptor agonists. 6.impairment when the drug is taken in the middle of the night. H.12 50. Sleep Hygiene: 1. Benzodiazepines with long half-lives. Agents Used for Insomnia Agent Dosage Ave Halflife of Meta bolite s 3 hours Comments Zolpid em (Ambi en) 5-10 mg qhs Nonbenzodiazepine . no daytime hangover Short acting. 25-50 mg at bedtime. 4. Avoid large meals before bedtime.

The disorder causes significant distress or impairment in social or occupational functioning. III. B. Tricyc lic Antidepress ants Doxep in (Sineq uan) Antihi stami nes Diphe nhydr amine (Bena dryl) 50100 mg Long Anticholin ergic side effects 50 mg NA Limited efficacy for mild initial insomnia. II. Modafinil (Provigil) is a non-amphetamine stimulantapprovedfor treatmentofexcessive .For daytime sleepiness stimulants such as amphetamine or methylphenidate (Ritalin).Tema zepa m (Resto ril) Fluraz epam (Dalm ane) 7. C. D. mood. C. B. active metab olites long t ½ Hangover is com­ mon. IV. Clinical Features A.5­ 30 mg qhs 15-30 mg qhs 11 hours Short act­ ing 100 hours. Excessive somnolence occurs for one month in the absence of physical or medical condition and is associated with daytime sleepiness. are useful. DSM-IV Criteria for PrimaryHypersomnia A. Differential Diagnosis A. The disorder is not due to the effects of medication.Treatment. or psychotic disorders may present with hypersomnia. Primary Hypersomnia I. Substance abuse. B. drugs of abuse. Can be associated with autonomic dysfunction. Sleep architecture is normal. Can accumu­ late in elderly. Atypicaldepression and thedepressed phase of bipolar illness may present withhypersomnia as an isolated symptom. or a medical condition. Depression often coexists. given in the morning. May be familial. anxiety.

depression. Excessive daytime sleepiness. B. and anxiety disorders. primary hypersomnia.such as methylphenidate (Ritalin). The disorder causes significant distress or impairment in social or occupational functioning. D. medication or general medical condition such as arthritis. frequent arousals. III. breathing-related disorders. substance abuse. IV. DifferentialDiagnosis: Sleep deprivation. The disturbance is not due to another mental disorder (eg. such as depression. sleep paralysis. DSM-IV Criteria for Breathing-Related Sleep Disorder A. Apnea can be central due to brain . poor concentration. Nocturnalpolysomnographydemonstrates apneic episodes. C. Clinical Features A. C. B. hypersomnia associated with mental disorder. Sleep attacks with abnormal manifestations of rapid eye movement sleep during the day(hallucinations. II. The disorder is not due to the effects of medication. Modafinil is effective at a dosage of 200 mg given in the morning. drugs of abuse. C. Sudden onset of sleep (cataplexy) can be triggered by strong emotions. Social reticence occurs due to fear of having sleep attack. cataplexy). Narcolepsy I. restless sleep. or a medical condition. are sometimes combined with tricyclic antidepressants (Protriptyline10-20 mg) before bedtime. B. depression) or to the effect of drugs of abuse. Breathing-Related Sleep Disorder (Sleep Apnea) I. Sleep apnea is associated with snoring. Sleep disruption leading to daytime sleepiness due to a sleep-related condition. sleep onset REM. II. Narcolepsy is often associated with mood disorders. DSM-IV Criteria for Narcolepsy A. Clinical Features A. Modafinil (Provigil) is a non-amphetamine stimulantapproved for treatmentof excessive daytimesleepiness associated withnarcolepsy. substance abuse. memory disturbance. Modafinil is effective at a dosage of 200 mg given in the morning. and generalized anxiety disorder. The disorder causes significant distress or impairment in social or occupational functioning. Maybe familial (>90% have HLA-DR2). or a medical condition. and decreased slow wave and rapid eye movement sleep. 10 mg bid or tid.Treatment:Stimulants.daytime sleepiness associated withnarcolepsy. C. B.

C. Dyssomnias Not Otherwise Specified I.Treatment A.stem dysfunction or obstructive due to airway obstruction. IV. The disorder is not due to the effects of medication. B. The body naturally adapts to time shifts within one week. opioids or carbamazepine can be helpful.nasal surgery. Nasal continuous positive airway pressure (NCPAP) is the treatment of choice. Common in elderly (40%). Nocturnal Myoclonus (periodic leg movements) A. B. The disorder causes significant distress or impairment in social or occupational functioning. With jet lag and shift work. Circadian Rhythm Sleep Disorder I. DifferentialDiagnosis: Other Dyssomnias. Obstructive sleep apnea is the most common type. B. DSM-IV Criteria for Circadian Rhythm Sleep Disorder A. Zolpidem (Ambien) or triazolam (Halcion) can be used to correct sleep pattern. B. medical conditions and substance abuse or withdrawalmaycause sleep disturbances. . Standard treatments include L-dopa and benzodiazepines. Common in middle age (5%). III.benzodiazepines. Restless Legs Syndrome A. Weightloss. Massage.propranolol. performance can be impaired during wakefulness. II. C. Clinical Features A. B. Mood disorders such as depression and mania can be precipitated by sleep deprivation. Treatment A. B. Results in frequentarousals and daytime somnolence.and uvuloplasty are also indicated if theyare contributing to the apnea. or can be idiopathic. drugs of abuse. C. Misalignment between desired and actual sleep periods. D. III. Abrupt contractions of leg muscles. or a medical condition. which can occur with jet lag or shift work. II. Painful or uncomfortable sensations in calves when sitting or lying down.

6. using.Tolerance: An increased amount of substance is required to achieve the same effect. III. or a decreased effect results when the same amount is used.Substance use during hazardous activities. Substance Abuse A.impaired judgement. or home obligations. 3.The patient attempts or desires to decrease use. B. or recovering from the substance. 2. Intoxication is defined as a reversible syndrome that develops following ingestion of a substance. II. 4.Withdrawal:Acharacteristic withdrawal syndrome occurs.buthas lead toimpairment or distress as indicated by at least one of the following during a 12-month period: 1. or the substance isused in an effortto avoid withdrawal symptoms.Failure to meet work. but that knowledge . school. Substance Intoxication A.The substance is used in increasingly larger amounts or over a longer period of time than desired. behavioral or psychological changes occur. Substance use has not met criteria for dependence. occupational. 3. The diagnosisofsubstancedependence requires substance use. suchasmood lability. 2. accompanied by impairment. Substance Dependence A. 4.Substance Abuse Disorders Substance-Related Disorders DSM-IV Diagnostic Criteria Substance-Related Disorders I. Significant maladaptive.Recurrent substance-related legal problems. and the presence of three of the following in a 12-month period: 1.Continued use of the substance despite continued social problems. 5. and impaired social or occupational functioning due to ingestion of the substance.Substance use resultsinadecreased amount of time spent in social. 7.A significant amount of time is spent obtaining.The patient has knowledge that the substance use is detrimental to his health.or recreational activities.

The patient should be assessed for the withdrawal symptoms. B. ascites. Intranasal cocaine use may cause damaged nasal mucosa.Work or School Manifestations. Asubstance-specificsyndromedevelops after cessation or reduction in the amount of substance used. spider angioma. motor vehicle accidents.Irresponsible borrowing or owing money. Thesyndrome causes clinicallysignificant distress or impairment. C. stealing. Clinical Evaluation of Substance Abuse A. 4. B. and day. Arrests for disturbing the peace or driving while intoxicated. Substance Withdrawal A.Legal Manifestations. the number of days per week alcohol is consumed. Substance-Induced Disorders A. Symptoms are not due to a medical condition or other mental disorder. prostitution. and sleep disorder. LaboratoryEvaluationofSubstance . impaired liver function. or cannabis. marital problems. divorce physical abuse and violence.Financial Manifestations. drug dealing. Effects of Substance Use on the Patient's Life 1. IV drug abuse maybe associated with injection site scars and bacterial endocarditis. persisting amnestic disorder. VI. Physical Examination A. hypnotics.Social Manifestations. Mydriasis (dilated pupils) is often seen in persons under the influence of stimulants or hallucinogens. Alienation and loss of friends. psychotic disorder. VIII. C. week. frequent absences. dementia. Decline in work school performance. selling of possessions. The physician should determine the amount and frequency of alcohol or other drug use in the past month. Nystagmus is often seen in abusers of sedatives. B. For alcohol use. 5. and signs of poor nutrition are indicators of chronic alcohol use. or in withdrawal from opiates. such as an enlarged liver. Family dysfunction. 3. mood disorder. Diagnosis requires meeting criteria for specific disorder with evidence that substance intoxication and not another condition (medical disorder) has caused the symptoms. frequent job changes. V.Family Manifestations.and the quantityconsumed should be determined. sexual dysfunction. VII.requests forworkexcuses. IV. B. gravitation toward others with similar lifestyle.does not deter continued use. anxiety disorder. Miosis (pinpoint pupils) is a classic sign of opioid intoxication. Substance-induced disorders include delirium. 2.

Impaired liver function and hematologic abnormalities are common. When risk factors are present HIV and Hepatitis C testing should be done. and serology should be completed on all patients. A UA.Abuse A. thyroid hormone. CBC. D. . Illicit drugs may be detected in blood and urine. chemistry panel. C. B. liver function tests.

Specific Substance-Induced Disorders Intoxication delirium Alcohol Amphetamine Caffeine Cannabis Cocaine Hallucinogens Inhalants Opioids PCP Sedative hypnotic I I I I I I IW I I I Withdrawal delirium Dementia Psychotic disorder Mood disorder Anxiety disorder Sexual dysfunction I I Sleep disorder W P IW I IW IW IW I IW IW I I IW I I I IW I I I I W P I I I I I I IW I I I W I IW IW P IW I = intoxication W = withdrawal P = persisting .

anxiety. 2.” the risk for respiratorydepression is increased. unsteadygait. Detoxification may be necessary after prolonged use of central nervous system depressants. mydriasis (dilated pupils). Diagnostic Criteria for Intoxication 1. high or low blood pressure. Provide a supervised stepwise dose reduction ofthe drugorsubstitute a cross-tolerant. 2. or impaired judgement. Cocaine A. Hypnotics. Withdrawal from Alcohol and other Sedatives 1. Two or more ofthe following:tachycardia or bradycardia. 2. Sedatives associated withwithdrawal syndromesincludealcohol. Tolerance develops to sedative effects. E. Amnesia is often present. the dose of medication should be reduced gradually over 1-2 weeks.” C. are present. hyperactivity. 2. Alcohol. II. chills or perspiration. longer-acting substance (diazepam). as users require higher doses to achieve a “high.benzodiazepines. Behavioral and psychological changes are present. Psychological or behavioral changes. and Anxiolytics A. Clinical Features of Intoxication 1. To prevent withdrawal symptoms. Detoxification of Patients Dependent on Alcohol. One or more of the following: slurred speech. Sedatives. 2. nausea or . grandiosity. impaired attention or memory. Diagnostic Criteria for Intoxication 1. or when there are signs of abuse or addiction. and chloral hydrate. B. Addiction 1. incoordination. such as euphoria. Because the brainstem develops tolerance to the respiratorydepressant effects more slowly.nystagmus. Dependence is associated with the development of tolerance to sedative effects.Specific Substance-Related Disorders I. Tolerance to brainstem depressant effects develops more slowly. Sedatives or Hypnotics 1. stupor or coma. 3. Behavioral disinhibition (aggressive or sexual activity) is a common finding. the risk for respiratory depression is increased. As users require higher doses to achieve a “high. which has less risk of severe withdrawal symptoms. 2. D. barbiturates. hypersexuality. The cross-tolerated drug is given in gradually tapering doses.

such as euphoria. withdrawal generally remits in 2-5 days.and psychomotorretardation. 2. weight loss. Tolerance develops with repeated use.vomiting. or impaired social or occupational functioning. B. and an intense craving for the drug. Chronic use is associated with paranoid ideation. Drug craving may last for months. Behavioral or psychological changes. depression. 2.coma. poor judgement. D. and arrhythmias.or impairment in attention or memory. Withdrawal 1. Overdose can result in coma.Psychological dependence is frequent.Tolerance and dependence develops rapidly. E. hypersomnia. Addiction. insomnia. dysphoria.dyskinesias. Pinpoint pupils (meiosis). Addiction. psychomotorretardation. anhedonia. poor concentration. coma. Treatment 1. 2. and personalitychange are common. such as heroin.weakness. C. Clinical Features of Cocaine Abuse 1. D. and perceptual disturbances. B. Initial euphoria is followed byapathy. agitation or retardation. C. Diagnosis of withdrawal requires the presence of three or more of the following: dysphoria. confusion. One of the following: drowsiness.arrhythmias. 3. peaks in 2-3 days and can last up to 10 days. Withdrawalischaracterized bydepression. III. slurred speech. fatigue. impulsivebehavior. cerebral infarcts. followed by dysphoria. Tricyclic antidepressants(desipramine). impaired judgement.andcarbamazepine may decrease craving and are often adjuncts to treatment. Heroin withdrawal begins eight hours after the last use. Intensityof the withdrawal syndrome is greatest with opiates that have a short half-life.amantadine. 2. 3. respiratorydepression. Opioids A. skin abscesses. nausea. Diagnostic Criteria for Intoxication 1. aggressive behavior. and death. clonidine. nasal congestion and bleeding. Hospitalization is sometimes required during the withdrawal phase of treatment because of the intense craving. . 2. Intoxication can resultin euphoria. Irritability. and weight loss. Physical sequelae include seizures. or dystonia. Clinical Features of Opioid Abuse 1.seizures. and bacterial endocarditis. anxiety.respiratory depression. IV use is associated with risk of AIDS.

2. and confusion. hyperacusis. 4. B. psychosis. belligerence. Phencyclidine Abuse A. decreased pain sensitivity. For patientswithrespiratorycompromise an airway should be established and naloxone (0. diaphoresis. seizure or coma. Medical support is required if the patient is unconscious. Perceptual disturbances include paranoia. mydriasis. E. Behavioral changes. Withdrawal symptoms can be managed with methadone (20-80 mg/day) or clonidine (given orally or by patch). but tolerance to the effects can occur. diarrhea. 2. D. fever.1-0. yawning. difficulty communicating. and insomnia. Physical Examination: Fever. catatonia.(AlsoseeOpiateDependance. Toxicology: PCP can be detected in urine forupto5days after ingestion. Treatment of Phencyclidine Abuse 1.3 mg qid) is effective and is usually used as a first-line treatment of withdrawal. . impairment of attention or memory.vomiting.hallucinations. Behavior changesinclude violence. page 10) IV. piloerection.4 mg IV) should be given immediately. Psychosis is often refractory to treatment with antipsychotics. hypertension or tachycardia. C. 3. Addiction: No evidence of physical dependence occurs. sweating. slurred speech. rhinorrhea. E. Clonidine (0. but drugs with anticholinergic side effects (phenothiazines) should be avoided due to the intrinsic anticholinergic effects of PCP. 2. muscle rigidity. 2. Atleasttwo ofthe following:nystagmus. Haloperidol (Haldol [2-4 mg IM/PO]) every two hours can be used. Clinical Features of Phencyclidine Abuse 1.muscle aches. hyperactivity. 3. mydriasis. Diagnostic Criteria for Intoxication 1. ataxia. IM or IV). anxiety. Withdrawal: Signs of depression can occur during withdrawal. Treatment of Heroin Addiction 1. Benzodiazepines are the treatment of choice (lorazepam 2-4 mg PO. lacrimation.

After abrupt cessation or reduction in the amount of nicotine used. Nicotine A. Diagnostic Criteria for Amphetamine Intoxication 1. insomnia. Crystal) A.or 4­ mg piece/30 min . D.poor concentration. B. four or more of the following occur within 24 hours:dysphoria. Amphetamine (Speed. D.agitation. Depression and suicidal ideation can develop. requiring increasing doses to achieve usual effect. C. Treatment 1. irritability. Craving is often prominent. 2. poor compli­ ance Nico­ tine gum (Nicor ette) 2. Addiction: Tolerance develops rapidly. anxiety. B. hyperactivity. increased appetite. or irritability. 2. Nicorettegumornicotine transdermal patches relievewithdrawal symptoms. Amphetamine Withdrawal 1. Intoxication does not occur. insomnia. vivid dreaming. Benzodiazepinessuchasdiazepam or lorazepam may also help calm the patient. decreased heart rate. VI. E. hypersomnia.hypervigilance. fatigue. Treatment 1. Diagnostic Criteria for Withdrawal 1. C. Developmentofdelusionsorhalucinations l are not unusual in chronic heavy users. Addiction:Physical tolerance develops.Psychological dependence is frequent. Generally resolves in one week and is associated with increased appetite. psychomotor agitation or retardation.V. Clinical Features 1. Patients should be prescribed a regimen that provides a tapering dose over a period of weeks. restlessness.anxiety. 2. Euphoria and increased energy is common in new users. Behavioral or psychologicalchanges such as euphoria. rapid speech. E. Antipsychotics can be used if psychosis is present. Clinical Features 1. Treatments for Smoking Cessation Drug Dosage Comments Available OTC.

provides low doses of nicotine Treatment initiated 1 wk before quit day. nasal irritation initially Mimics smoking behavior. similar to smoking. then titrate to 300 mg F. Bupropion is contraindicated with a history of seizures. Nicotine inhaler (Nicotrol Inhaler) delivers nicotine orally via inhalation from a plastic tube. . 2. Nicode rm CQ) Nico­ tine nasal spray (Nicotr ol NS) Nico­ tine inhaler (Nicotr ol In­ haler) Bupro pion (Zyban ) 1 patch/d for 6-12 wk. The treatment is associated with reduced weight gain. then taper for 4 wk 1-2 doses/h for 6-8 wk Rapid nic­ otine deliv­ ery. Bupropion (Zyban) 1. Nicotine nasal spray (Nicotrol NS) is available by prescription and is a good choice for heavy smokers or patients who have failed treatment with nicotine gum or patch.Drug Dosage Comments Available OTC. Bupropion is appropriate for patients who have been unsuccessful using nicotine replacement. contraindi­ cated with seizures. Tapering over about six weeks. heavyalcohol use. Bupropion reduces withdrawal symptoms and can be used in conjunction with nicotine replacement therapy. or head trauma. The sprayis used 6-8 weeks. H. at 1-2 doses per hour (one puff in each nostril). similar to nicotine gum. anorexia. It is available by prescription and has a success rate of 28%. It delivers a high level of nicotine. anorexia. heavy al­ cohol use 6-16 car­ tridges/d for 12 wk 150 mg/day for 3 d. local skin reac­ tions Nico­ tine patch (Habitr ol. G. Bupropion is started at a dose of 150 mg daily for three days.

. the abstinence rates increase to 50% compared with 32% when only the patch is used. When a nicotine patch is added to this regimen. Bupropion is then continued for three months.then increased to 300 mg daily for two weeks before the patient stops smoking. References References. see page 121.

A fluctuating clinical presentation is the hallmark of the disorder. E. falling. sustain or shift attention. D. and the patient may have moments of lucidity during the course of the day. D. Sleep-wake cycle disturbances are common. The incidence of delirium in hospitalized patients is 10-15%. Perceptual disturbances may take the form of misinterpretations.Cognitive Disorders Delirium I. Clinical Features of Delirium A. B. Delirium due to a general medical condition (specify which condition). illusions or frank hallucinations. with higher rates in the elderly. The change in cognition or perceptual disturbance is not due to dementia. resulting in pulling out of IVS and catheters. awareness of environment. but other sensorymodalitiescanalsobemisperceived. C. Injuries may occur when the patient isdelirious and agitated and unrecognized delirium may result in permanent cognitive impairment. B. Classification of Delirium A. Disturbance of consciousness with reduced ability to focus. Delirium due to substance intoxication (specify which substance). E. Many patients are disoriented and display disorganized thinking. The disturbance develops over a short period of time (hours to days) and fluctuates during the course of the day. Delirium not otherwise specified . B.attention and concentration. and combative behavior. Infection and medication interaction or toxicity is a common cause of delirium in the elderly. Other patients at risk include those with CNS disorders. There is clinical evidence that the disturbance is caused by a general medical condition and/or substance use or withdrawal. II. and HIV-positive patients. D. Delirium due to a substance withdrawal (specify which substance). Delirium is characterized byimpairments of consciousness. Delirium due to a multiple etiologies (specify which conditions).Thehallucinations are most commonly visual. Failure to report use of medications or substance abuse is a common cause ofwithdrawal deliriuminhospitalized patients. substance abusers. C. F. C. and psychomotor agitation can be severe. DSM-IV Diagnostic Criteria for Delirium A. The quietly delirious patient may reduce fluid and food intakewithoutovertlydisplaying agitated behavior. III.

Physical restraints may be necessary to prevent injury to self or others. V. In delirium. Informationfromfamilyor caretakers is helpful in determining whether there was a pre-existing dementia. Psychotic Disorders and Mood Disorders with Psychotic Features. B. Differential Diagnosis of Delirium A. Haloperidol is the only antipsychotic available in IV form. IM or IV. Most cases of delirium are treated bycorrecting the underlying condition. confusion.(unknown etiology or due to other causes such as sensory deprivation). It may cause increased confusion. D. there should be some evidence of an underlying medical or substance-related condition. B.Parenteral forms of ziprasidone (Geodon) and olanzapine (Zyprexa) may have a role in managing delirium. Delirium can be distinguished from psychotic symptoms by the abrupt development of cognitive deficits including disturbance ofconsciousness. A quietenvironmentwithclose observation should be provided. 1-2 mg given every 4-8 hours. Agitation. If patients are willing to take oral medication. Malingering. Intravenous administration may be necessary in medically ill patients. low-potency medication quetiapine (Seroquel) 12. Agitation can also be treated with lorazepam (Ativan). E.small doses ofthe sedating. .5-25 mg every 4-8 hours can be veryeffective. Dementia 1. 2. Haloperidol may also be given IM. The major difference between dementia and delirium is that demented patients are alert without the disturbance of consciousness characteristic of delirious patients. IV. C. and perceptual disturbances mayrequire treatment with haloperidol (Haldol). Monitoring of heart rate and blood pressure is necessary in patients receiving more than two dosesperday. 1-2 mg every 2-6 hours PO. Treatment of Delirium A. It should be used cautiously in patients with respiratorydysfunction. Lorazepam is safe in the elderlyand those patients with compromised renal or hepatic function. Patients with malingering lack objective evidence of a medical or substance-related condition. C. Dementia is the most common disorder that must be distinguished from delirium.

The deficits are not the result of delirium. Vascular dementia is the second most common cause of dementia. Aphasia (language disturbance). Patients are often unaware of their deficits. Disturbance in executive functioning (abstract thinking. C. The development of multiple cognitive deficits manifested by: 1. Paranoid delusions (especiallyaccusations that others are stealing items) and hallucinations (especially visual) are common. Once the dementia is well established. 3. One or more of the following: a. accounting for 13% of all cases. Patients may overestimate their ability to safely carry out specific tasks. Three percent of patients over 65 years old have dementia.Dementia I. IV. Psychiatric symptoms are common and patients frequentlymanifest symptoms of anxiety. Apraxia (impaired ability to carry outpurposeful movement. Clinical Features of Dementia A. DSM-IV Diagnostic Criteria for Dementia A. cooking. b.comprising 50-60% of all cases. Poor insight and impaired judgment are common features of dementia. d. depression. but after age 85. and sleep disturbance. The prevalence of dementia increases with age. D. Epidemiology of Dementia A. planning and carrying out tasks). Agnosia (failure to recognize or identify objects). 1. B. or shopping. Alzheimer's type dementia is the most commontype ofdementia. 2. Memory impairment. 2. Classification of Dementia . 20% of the population is affected. C. The cognitive deficits cause significant social and occupational impairment and represent a significant decline from a previous level of functioning. B.suchasmakinginappropriate comments. II. patients may have great difficulty performing activities of daily living such as bathing. The memory impairment involves difficulty in learning new material and/or forgetting previously learned material. F. c. Delirium is frequently superimposed upon dementia because these patients are more sensitive to the effects of medications and physical illness. III.especially the use of objects). dressing. Disinhibition can lead to poor social judgment. B. Early signs may consist of losing belongings or getting lost more easily. E.

3. Cognitive deficits are not due to another medical condition or substance. or uncomplicated. AIDS-Related Dementia a. Alzheimer's Type Dementia 1.A. Meets basic diagnostic criteria for dementia.depressed mood. 2. b. c. multiple infarctions or MRI scan). social withdrawal. c. 3. b. 2. Focal neurological signs and symptoms or laboratoryevidence of cerebrovascular disease (eg. C. The one notable exception is dementia pugilistica. Dementia Due to Other General Medical Conditions 1. DementiaCaused byHead Trauma. d. The patient meets basic diagnostic criteria for dementia but also: a. c. Neurological symptoms are frequently present. which is caused by repeated trauma (eg.forgetfulness. 5. B. flat affect. Frank psychosis maybe present. The average life expectancy after onset of illness is 8-10 years. depressed mood. Alzheimer’s Disease is further classified as: a. leaving some cognitive functions intact. b. Unlike Alzheimer's disease. Dementia caused by the effect of the HIV virus on the brain. changes in functioning may be abrupt. oruncomplicated. Early or late onset.delusions. The dementia is often exaggerated bythe presence of major depression. Dementia caused byhead trauma usually does not progress.Deficits are highlyvariable depending on the location of the vascular lesions.delusions. boxing). Vascular Dementia (previously Multi-Infarct Dementia) 1. and the long-term course tends to have a stepwise pattern. but there must also be evidence that symptoms are the directphysiological consequence of a general medical condition. The patient meets basic diagnostic criteria for dementia but also has: a. impaired problem solving. Dementia Caused byParkinson's Disease. 4. Gradual onset and continued cognitive decline. b. Dementia is an inevitable outcome . Vascular dementia is further classified as withdelirium. Withdelirium. Clinical presentation includes psychomotorretardation. Symptoms are not caused by another psychiatric disorder. apathy.Dementia occurs in 40-60% of patients with Parkinson's disease. DementiaCaused byHuntington's Disease a.

Lewybodydementia is associated with repeated falls.whle memory. Substance-Induced Persisting Dementia 1. Dementia Due to Multiple Etiologies. Lewy Body Dementia a. When drugs of abuse are involved. Creutzfeldt-Jacob disease is asubacutespongiformencephalopathy caused by a prion.metcriteria for substance dependence. language and factual knowledge may be relatively preserved. There is evidence that the deficits are related to the persisting effects of substance use (specify which drug or medication). b. 7. The earlyphases of the disease are characterized bydisinhibition.of this disease. The clinical triad consists of dementia. at some time in their lives. dementia can precede the onset of motor symptoms. . c.and language abnormalities because Pick's disease affects the frontal and temporal lobes. Clinical presentation is that of a typical dementia. most patients have. involuntarymyoclonic movements. 8. Recurrent. b. i and executive function are more seriously impaired. b. Initially. D. well-formed visual hallucinations are also common.reasoning. The deficits persists beyond the usual duration ofsubstanceintoxication or withdrawal. Occasionally patients will improve mildly after thesubstanceusehasbeendiscontinued. 6. syncope. Later stages of the illness may byclinicallysimilar to Alzheimer's disease. DementiaCausedbyCreutzfeldt-Jakob Disease a. but most display a progressive downhill course. 2. transient loss of consciousness. neuroleptic sensitivity. Meets basic diagnostic criteria for Dementia but also: a. and periodic EEG activity. Brain imaging studies usually reveal frontal and/or temporal atrophy. 3. This diagnosis is applicable when multiple disorders are responsible for the dementia. apathy. DementiaCaused byPick's Disease a. E. b. Characterized by decline in cognition along with fluctuating levels of attention and alertness. Occasionally. delusions and hallucinations. b.

B.whereas. Amnestic Disorder is characterized by isolated memory disturbance. Differential Diagnosis of Dementia A. Delirium 1. 2. without the cognitive deficits seen in dementia. SLE) Neurological Normal pres­ sure hydroceph­ alus Huntington’s disease Parkinson’s dis­ ease Pick’s disease Brain tumor Multiple sclero­ sis Head trauma Cerebral an­ oxia/hypoxia Seizures Metabolic and Endocrine Hypothyroidism Hyperparathyroi dism Pituitary insuffi­ ciency Diabetes Hepatic encephalopathy Uremia Porphyria Wilson’s dis­ ease Toxicity Heavy metals Intracranial radi­ ation Post-infectious encephalomyelit is Chronic alcohol­ ism Nutritional Folate defi­ ciency Vitamin B12 deficiency Thiamine defi­ ciency (Wernicke Korsakoff syn­ drome) Pellagra Infections HIV Cryptococcal meningitis Encephalitis Sarcoid Neurosyphilis CreutzfeldtJakob disease Industrial chemicals V. Delirious patients demonstrate an acutely fluctuating clinical course. whereas demented patients displaya stable. Differentiation of delirium from dementia can be difficult because demented individuals are prone to developing a superimposed delirium. Demented patients are alert. slowlyprogressive. . delirious patients have an altered level of consciousness. Delirium is the most common disorder that maymimic dementia.General Medical Conditions That Can Cause Dementia Vascular Multiple in­ farcts Subacute bac­ terial endocarditis Congestive heart failure Collagen vas­ cular diseases (eg. downhill course.

especially in the elderly. themood symptoms shouldprecede the development of cognitive deficits and in dementia. B.Indepression. B. J. Treatment of Dementia A. such as a mass lesion or vascular event. G. 3. and impaired memory. should be completed. Brain Imaging (CT. EEG. Chest X-ray. Both dementia and depression may present with apathy. The family and/or caretakers should receive psychological support. Complete blood chemistry. A medical evaluation to rule out treatable causes of dementia or medical causes of depression should be completed. E. If the distinction between dementia and depression remains unclear. Laboratory Evaluation of Dementia A. VIII. Any underlying medical conditions should be corrected. poor concentration. B. Support groups. Patients function best if highlystimulating environments are avoided. Serological studies (VDRL or MHA-TP). VI. EKG. H. The use of CNS depressants and antichoinergic medications l should be minimized. andthisisreferredtoas“pseudodementia. Differentiation of dementia from depression can be difficult. atrialofantidepressants is warranted. L. psychotherapy. K. C. Some causes of dementia are treatable and reversible. C. Serum levels ofall measurable medications. Treatment of Alzheimer's Disease 1. MRI) is indicated if there is a suspicion of CNS pathology. I. Vitamin B12 level. All patients presenting with cognitive deficits shouldbeevaluated todetermine the etiology of the dementia. with special attention to the neurological exam. Major Depressive Disorder 1. A medical and psychiatric history and a physicalexamination and psychiatric assessment. 4. If the depression is superimposed on the dementia. D. Thyroid function tests. Demented patients are often alsodepressed. M. Cognitive deficits due to a mood disordermayappear tobe dementia. Donepezil (Aricept)andGalantamine . Clinical Evaluation of Dementia A.C. and day-care centers are helpful. and the cognitive symptoms should precede the depression.” 2. Heavy metal screen. VII. CBC with differential. F. Drug screen. Urinalysis. treatment of the depression will improve the functional level of the patient.

Buspirone (BuSpar) beginning at 5 mg bid with a final dose of 30-50 mg/day in bid or tid dosing. 2.5-25 mg po qhs with an increase of 12. Tacrine (Cognex) is a less specific esterase inhibitor that requires monitoring of AST and SLT levels. a. There is no hepatic toxicity.0 mg po bid for 4 weeks. a. D. They work bycentral. which (after 4-6 weeks) may be increased to 10 mg qhs ifnecessary. Beginning dose is 5 mg qhs for donepezil. then increased to 8. E. Dosing is begun at 1. 2. and increased to 4. Pharmacotherapy: The following agents have significant efficacy in reducing agitation and aggression in dementia. b. Several weeks are required to achieve full benefit. Ri asi mine(Exelon)isanacetychoinest rase v tg l l e inhibitor with a similar mechanism of action asdonepeziland galantamine.diarrhea and syncope. It may slow progress of the disease. and then up to 12 mg po bid. Quetiapine (Seroquel) 12. b. Hypertension must be controlled. Buspirone has fewside effects and no significant drug interactions. Side effects include GI upset or diarrhea.5 mg bid. Risperidone (Risperdal). Galantamine (Reminyl)is initiated at 4. 3. reversible inhibition of acetylcholinesterase thereby increasing CNSlevels ofacetylcholine.0 mg po bid if tolerated for 4 weeks.(Reminyl) are the drugs of choice for improving cognitive functioning in Alzheimer’s dementia. d. The most common side effects are nausea. GI side effects are reduced by coadministration with food. b. Agitation and Aggression 1. a. Vitamin E and selegiline (Deprenyl) may also have a role in slowingthe progression ofdementia.beginning . Aspirin may be indicated to reduce thrombus formation. c. Trazodone (Desyrel) beginning at 25-50 mg qhs with an average dose of 50-200 mg/day.5 mg bid and then 6. Vitamin E. Tacrineisnotusedduetoitshepatotoxicity. Treatment of Vascular Dementia 1.5 to 25 mg every1-3 days if needed to an average dose of25-200 mg/dayand amaximum dose of 400-600 mg/day.Donepezil has no reported hepatic toxicity or significant drug interactions.0 mg bid at two-week intervals. 4. Efficacy is greatest at the higher dose.

Several days should elapse between dosageincreasestopreventovermedication and oversedation. and potential for disinhibition and physical dependence. also reduces agitation in dementia. i. References References. Depression 1.5-1.0 mg q 4 hours prn. trazodone (Desyrel). . e. h. bupropion (Wellbutrin). butit is notrecommended l for long-term use because of ataxia.5 mg BID to 150 mg bid) is useful.5 mg qhs with an average dose of 2. High-potencytypical antipsychotics. f. can provide rapidreief. Venlafaxine (Effexor) (37. and olanzapine are less likelyto produce extrapyramidal symptoms and are preferred over typical antipsychotics. 2.beginning at 2.5 mg qhs with an average dose of 2.5-2 mg day. SSRIs are first-line antidepressants in the elderly. 2.is especially effective for agitation associated with psychotic symptoms such as paranoia.5mgqhs withan average dose of 0. Quetiapine. 0. nefazodone (Serzone) and mirtazapine (Remeron) may also be used if SSRIs are ineffective. see page 121.5-7. Lorazepam (Ativan). F.further memoryimpairment. Ziprasidone (Geodon) 20 mg po bid with increases of 20 mg every 1-3 days as needed with maximum daily dose of 80 mg po bid. risperidone. G. Serum levels should be maintained between 25-75 mg/mL. Olanzapine(Zyprexa). Psychosis 1.at0. Dose range is 0. g. Tricyclic antidepressants should be avoided in patients with dementia because of their anticholinergic effects. ziprasidone.5-5 mg/day given qhs or bid. Divalproex (Depakote) at a dosage of10 mg/kg/day(250-1250 mg/day bid) is effective and well tolerated bymanydemented patients. such as haloperidol or fluphenazine.5 mg qhs.25-0.5-7. Haloperidol (Haldol) may be used if risperidone or olanzapine are ineffective. should be given only at very low doses.

Somatic and persecutory delusions are the mostcommon typesofdelusions associated with a medical condition. ClinicalFeaturesofPsychoticDisorder Due to a General Medical Condition 1. There is evidence from the history. DSM-IV Diagnostic Criteria for Mental Disorder Due to a Medical Condition A. 2. The disturbance is not caused by delirium. Primary Psychotic Disorders a. olfactory and tactile elements more often than in primarypsychotic disorders. The disturbance isnot better accounted for by another mental disorder. Hallucinations caused bya medical condition include visual. Non-auditory . Common Disorders Associated with Psychosis Addison's dis­ ease CNS infections CNS neoplasms CNS trauma Cushing's dis­ ease Delirium Dementias Folic acid defi­ ciency Huntington's chorea Multiple sclero­ sis Myxedema Pancreatitis Pellagra Pernicious anemia Porphyria Lupus Temporal lobe epilepsy Thyrotoxicosis C. Temporal Lobe Epilepsyisacommon medical condition associated with olfactoryhallucinations. physical examination. Diagnostic Criteria. B. Differential Diagnosis of Psychotic Disorder Due to a General Medical Condition 1. C. b. The patient meets the criteria for a mental disorder due to a general medical condition and there are prominent hallucinations or delusions. or laboratory studies that the symptoms are a direct physiological consequence of a general medical condition. The onset of illness in a primary psychotic disorder is usually earlier (before age 35). with symptoms beginning prior to the onset of the medical illness. II. Psychotic DisorderCaused byaGeneral Medical Condition A. Complex auditory hallucinations are more characteristic of primary psychotic disorders. B.Mental Disorders Due to a Medical Condition I.

b. 2. The underlying medical conditions should be corrected. activities. Mood disorder due to a general medical condition with manic features. or irritable mood. 2.L-dopa. Mood DisorderDuetoa General Medical Condition A. D. 2. b.and disulfiram. d. hallucinogens. A trial of antipsychotic medication may be necessary to manage symptoms while the patient's medical condition is being treated. Substances that can cause psychosis: anticholinergics.tactilehallucinations) are more commonly seen in general medical conditions. Diagnostic Criteria. Blood or urine screens for suspected substances may be helpful in establishing this diagnosis. 2. c.ifnot all. Subtypes include: a. Treatment of Psychotic Disorder Due to a General MedicalCondition 1. withdrawal from a substance is the likelycause. Meets criteria for a mental disorder due to a general medical condition.hallucinations (eg. Clinical Features of Mood Disorder Due to a General Medical Condition 1. cocaine. Elevated. Mood disorder due to a general medical condition with mixed features.amphetamines. steroids. . When psychosis is associated with recentorprolonged substance use. and the presence of a prominent and persistent mood disturbance characterized by either or both of the following: 1. Substance-Induced Psychotic Disorder a. With depressed mood or lack ofpleasure in most. expansive. III. Mood disorder due to a general medical condition with depressive features. The mood symptoms cannot be a merely psychological reaction to being ill. B. Mood disorder due to a general medical condition with major depressive-like episode.

Common Diseases and Disorders Associated with Depressive Syndromes Addison's dis­ ease AIDS Asthma Chronic infec­ tion (mononu­ cleosis, tuberculosis) Heart failure Cushing's dis­ ease Diabetes Hyperthyroidis m Hypothyroidism Infectious hep­ atitis Influenza Malignancies Malnutrition Anemia Multiple sclero­ sis Porphyria Rheumatoid arthritis Syphilis Lupus Uremia Ulcerative coli­ tis

C. Differential Diagnosis of Mood Disorder Due to a General Medical Condition 1. Primary Mood Disorder. If a clear causativephysiologicalexplanation cannot be established between mood symptoms and the medical condition, a primarymood disorder should be diagnosed. Fluctuation of mood symptoms during the course of medical illness is indicative of a disorder due to a medical condition. 2. Substance-Induced Mood Disorder a. When the mood disorder is associated withrecentor prolonged substance use or withdrawal from a substance and psychotic symptoms,a substance-induced mood should be diagnosed. Blood or urine screens may be helpful in establishing this diagnosis. b. Common substances that can cause depressive syndromes include antihypertensives, hormones (cortisone, estrogen, progesterone), antiparkinsonian drugs,benzodiazepines, alcohol, chronic use ofsympathomimetics, i andwthdrawalfrompsychostimulants. 3. Treatment of Mood Disorder DuetoaGeneralMedical Condition. The underlying medical condition should be corrected. References References, see page 121.

Eating Disorders

Anorexia Nervosa I. DSM-IV Diagnostic Criteria for Anorexia Nervosa A. The patient refuses to maintain weight above 85% of expected weight for age and height. B. Intense fear of weight gain or of being fat, even though underweight. C. Disturbance in the perception of ones weight and shape, or denial of seriousness of current low weight. D. Amenorrheaforthreecyclesinpost-menarchal females. II. Classification of Anorexia Nervosa A. Restricting Type or Excessive Dieting Type. Binging or purging are not present. B. Binge-Eating Type or Purging Type. Regular binging and purging behavior occurs during current episode (purging maybe in the form of vomiting, laxative abuse, enema abuse, or diuretic abuse). III. Clinical Features of Anorexia Nervosa A. Anorexia nervosa is characterized by obsessive-compulsive features (counting calories, hoarding food), diminished sexual activity, rigid personality, strongneed tocontrolonesenvironment, and social phobia (fear of eating in public). Anorexia nervosa commonly coexistswith major depressive disorder. B. Complications of Anorexia Nervosa. All body systems may be affected, depending on the degree of starvation and the type of purging. Leukopenia and anemia, dehydration, metabolic acidosis (due to laxatives), or alkalosis (due to vomiting), diminished thyroid function, low sex hormone levels, osteoporosis,bradycardia,andencephalopathy are commonly seen. C. Physical signs and symptoms may include gastrointestinal complaints, cold intolerance, emaciation, parotid gland enlargement, lanugo hair, hypotension, peripheral edema, poor dentition, and lethargy. IV. Epidemiology of Anorexia Nervosa A. Ninety percent of cases occur in females. The prevalence in females is 0.5-1.0%. The disorder begins in early adolescence and is rare after the age of forty. Peak incidences occur at age 14 and at age 18 years. B. There is an increased risk in first-degree relatives,and there is a higher concordance rate in monozygotic twins. Patients withahistoryofhospitalization secondary to anorexia have a 10% mortality rate. V. Differential Diagnosis of Anorexia Nervosa A. Medical Conditions. Malignancies,

AIDS, superior mesenteric artery syndrome (postprandial vomiting due to gastric outlet obstruction) are not associated with a distorted body image nor the desire to lose weight. B. BodyDysmorphic Disorder.Additional distortions of body image must be present to diagnose this disorder. C. Bulimia Nervosa. These patients are usually able to maintain weight at or above the expected minimum. VI. Laboratory Evaluation of Anorexia Nervosa. Decreased serum albumin, globulin,calcium hypokalemia,hyponatremia, anemia, and leukopenia maybe present. ECG may show prolonged QT interval or arrhythmias. VII.Treatment of Anorexia Nervosa A. Psychotherapiesinclude psychodynamic psychotherapy,familytherapy,behavioral therapy, and group therapy. B. Pharmacotherapy of Anorexia Nervosa 1. Two-thirds ofpatients with anorexia or bulimia nervosa have a history of a major depressive episode. Fluoxetine (Prozac) has been used successfully in the therapy of anorexia and bulimia; 20-60 mg per day. 2. Hospitalization maybecomenecessary if weight loss becomes severe or if hypotension, syncope, or other cardiac problems develop. Specialized treatment programs, including behavioral treatment focusing on weight gain, family psychotherapy,oral intakemonitoring with dietary consultation, and pharmacotherapy are effective in motivated patients.Close monitoring of body weight and the general medical condition is warranted.

Bulimia Nervosa
I. DSM-IV Diagnostic Criteria for Bulimia Nervosa A. The patient engages in recurrent episodes of binging, characterized by eating an excessive amount of food within a two-hour span and by having a sense of lack of self-control over eating during the episode. B. The patient engages in recurrent compensatory behavior to prevent weight gain (eg, self-induced vomiting, laxative, diuretic, exercise abuse). C. The above occur on the average twice a week for three months. D. The patient’s self-evaluation is unduly influenced by body shape and weight. E. Thedisturbance does notoccurexclusively during episodes of anorexia nervosa. II. Classification of Bulimia Nervosa A. Purging Type Bulimia Nervosa.

3. B. but not vomiting or laxatives. Clinical Features of Bulimia Nervosa A. and laxatives. whether or not accompanied by major depression. VI. symptoms of binging and purging are reduced. and borderline personality disorder (30%) in bulimia patients. IV. and the incidence is 1-3% in adolescent and young adult females and 0. Antidepressant medications are useful in the treatment of bulimia nervosa. and obesityis more common.3% in males. substance abuse (30%). B. hypokalemia). V. 2. and concern over bodyshape and weightis notpredominant. Prognosis is generally better than for anorexia nervosa. Imipramine (Tofranil) or desipramine (Norpramin) at a low dosage (50 mg per day). Bulimia occurs primarilyin industrialized countries. Overeating occurs in the absence of compensatory purging behaviors. and various degrees of starvation can occur.The patient regularly makes use of self-induced vomiting. to a daily dose of 150 mg. . There is a higher incidence of affective disorders in families of patients with bulimia. III. Cognitive behavioral therapy is the most effective treatment. Psychodynamic group and family therapies are also useful. Loss of control. Bulimic patients tend to be ashamed of their behavior and often hide it from their families and physicians. Body weight is less than 85% of expected. Epidemiology of Bulimia Nervosa A. C. C. The serum drug level is measured after one week. increasing by 50-mg increments every 3-4 days.1-0. bulimic patients tend to be at or above their expected weight for age. Fluoxetine (Prozac) is effective at a dosage of 20-60 mg per day. B. Purging can be associated with poor dentition (because of acidic damage to teeth). Atypical Depression. concern with body shape. Pharmacotherapyof Bulimia Nervosa 1. There is an increased frequency of affective disorders. B. Other SSRIs are also effective. Treatment of Bulimia Nervosa A. The patient regularlyengages in fasting or exercise. Menstrual abnormalities are frequent. dehydration. Medical Conditions with Disturbed Eating Behaviors. Nonpurging Type Bulimia Nervosa. Differential Diagnosis of BulimiaNervosa A. Unlike anorexia patients. B. Binging Purging Type Anorexia Nervosa. and death rarely occurs in bulimia. Electrolyte abnormalities (metabolic alkalosis. and binging and purging behavior occurs. and weight are absent.

such as Major Depression. B. Subjective sense of difficulty in concentrating. 5. Patients who have continued symptoms after the onset of menses .” weight gain. DSM-IV Diagnostic Criteria A. began to remit soon after the onset of the follicular phase. or specific food cravings. Clinical Features of Premenstrual Dysphoric Disorder A.” 3. I. or self-deprecating thoughts. or a Personality Disorder. (2). D. 8. B and C must be confirmed by prospective daily ratings during at least two consecutive symptomatic cycles. and were absent in the week after menses. 10. The disturbance markedly interferes with work or school or usual social activities and relationships with others. such as breast tenderness or swelling.Panic Disorder.hopelessness. or marked lack of energy.Asubjectivesenseofbeingoverwhelmed or out of control. 9. 6. a sense of “bloating. Persistent and marked anger or irritabilityor increasedinterpersonal conflicts. Marked affective lability. In most menstrual cycles over the past year. tension. II.overeating. C. easy fatigability. Lethargy. Bupropion is contraindicated because of the increased risk of seizures in bulimic patients.Physical symptoms. References References. (3). Patients with PMDD do not experience symptoms in the week following menses. 11. joint or muscle pain. with at least one of the symptoms being either (1). Criteria A.Dysthymic Disorder. Decreased interest in activities. see page 121. feeling “keyed up” or “on edge. Marked anxiety. 7. 2. or (4): 1. Markedlydepressedmood. 4. The disturbance is not merely an exacerbation of the symptoms of another disorder.4. headaches. 5 or more symptoms were present most of the time in the last week of the luteal phase. Markedchange in appetite. Premenstrual Dysphoric Disorder Premenstrual Dysphoric Disorder (PMDD) is characterized by depressed mood prior to the onset of menses. Hypersomnia or insomnia.

such as bloating. Premenstrual Exacerbation of a Current Mood or AnxietyDisorder.mayhave another underlyingpsychiatric disorder. B. It is uncommon for women with dysmenorrhea to have PMDD and uncommon for women with PMDD to have dysmenorrhea. Antidepressants. are effective in reducing symptoms of PMDD. Anxiolytics. B. The dosage of fluoxetine (Sarafem) is 20 mg per day throughout the month. Many females experience mild transient affective symptoms around the time of their period. however. Sertraline (Zoloft) is also effective in treating PMDD. III. IV. V. Hormones.These individuals will continue to meet criteria for a mood or anxiety disorder throughout the menstrual cycle. such as fluoxetine (marketed as Sarafem for PMDD). Treatment of Premenstrual Dysphoric Disorder A. however. The prevalence of PMDD ranges from 2-10% in women. B. Concomitant unipolar depression or bipolar disorder or a family history of affective illness is common in patients with PMDD. C. progesterone and triphasic oral contraceptives may improve symptoms of PMDD in some patients. Onset usually occurs in the mid to late twenties. The most severe symptoms of PMDD usually occur in the few days prior to menses. These agents are often effective when given only during the luteal-phase. Estrogen. The dosage may be increased up to 60 mg per dayif necessary. EpidemiologyofPremenstrualDysphoric Disorder A. Females with disorders such as dysthymia or generalized anxiety disorder mayexperience a premenstrual exacerbation of their depressive or anxietysymptoms. PMDD is diagnosed only when symptoms lead to marked impairment in social and occupational functioning. Premenstrual Syndrome. Alprazolam (Xanax) and buspirone (BuSpar) may have efficacy in treating patients with mild symptoms of anxiety. D. Differential Diagnosis of Premenstrual Dysphoric Disorder A. onset in the teenage years may sometimes occur. Other SSRIs are equally effective. patients with PMDD have symptoms only prior to and during menses. Spironolactonemayimprove physical symptoms. Sertraline should be started at 50 mg per day and increased up to 150 mg if necessary. SSRIs. B. .

E. Moderate exercise can lead to improvement of physical and emotional symptoms of PMDD. . Exercise.

Brief to moderate courses are usually used. II. Indications for Antipsychotic Drugs A.ziprasidone and the low-potency typical agents.Low-dose neuroleptics maybe useful for the psychotic features ofsevere personalitydisorders. with the exception of clozapine. The use of more than one antipsychotic agent at a time has not been shown to increase efficacy. familyhistoryof response. Once steady state levels have been achieved (after about five days). Antipsychotics are the drugs of choice forbrief psychotic disorder. A. the long half-life of most neuroleptics allowsforonce-a-daydosing. and likelihood of tolerance to side effects. . These agents often improve functioning in patients with dementia or delirium with psychotic features when given in low doses. B. They also playa prominent role in the treatment of schizoaffective disorder. All neuroleptics are equally effective in the treatment of psychosis. D. Antipsychotics may be necessary for patients with mood disorders with psychotic features. Antipsychotics are frequently used in the treatment of substance induced psychoticdisorders. however. olanzapine. which is more effectivefor treatmentrefractoryschizophrenia. quetiapine. B. Symptoms will often continue to improve over the following months.Psychiatric Drug Therapy Antipsychotic Drug Therapy I. ziprasidone. such as two to four times per day. At least two weeks of treatment is required before significantantipsychotic effect is achieved. B. and these agents may be used for other disorders with psychotic features. Selection of an Antipsychotic Agent. The choice of neuroleptic should be made based on the past history of response to a particular neuroleptic. and aripiprazole) may be more effective than conventional agents. Initial treatment should begin with divideddoses ofthe chosen antipsychotic. III. Thenewer“atypical” antipsychotics (risperidone. Antipsychotics (also known as neuroleptics) are indicated for schizophrenia.however.schizophreniform disorder and schizophrenia. such as depression and bipolar disorder. C. These newer agents are called atypical because they affect dopamine receptors and also have prominenteffects on serotonergicreceptors. they should be used with caution and for a brief period of time in these patients. Dosing of Antipsychotic Agents A. Olanzapine (Zyprexa). can be initiated with once-a-day dosing.

Agitated psychotic patients are best treated initially with sedating agents such as benzodiazepines combined with a neuroleptic. should be given in divided doses. . C.such as chlorpromazine.

Classification of Antipsychotic Drugs Name Trade name Class Average Dose (mg) ChlorproDopaminermazine gic Equivalents Effect (D2) (mg) 100 ++++ Muscarinic Effect Alpha-1 Adrenergic Blocking Effect ++++ Antihis tamine Effect ++++ Serotone rgic Effect ++++ Chlorpromazine Fluphenazine Thorazine Prolixin Phenothia­ zine/Aliph atic Phenothia­ zine/Piper azine Phenothia­ zine/Piper azine Phenothia­ zine/Piper azine Phenothia­ zine/Piper idine Phenothia­ zine/Piper idine 600-800 ++++ 10-20 2 ++++ + + ++ ++ Perphenazine Trilafon 60-80 10 ++++ + ++ +++ ++++ Trifluoperazine Thioridazine Stelazine 30-40 5 ++++ + ++ ++ +++ Mellaril 600-800 100 ++++ ++++ ++++ ++++ ++++ Mesoridazine Serentil 300-400 50 ++++ +++ ++++ ++++ ++++ .

10-20 none Dibenzodiazepine Quinolinon e Dibenzodi azepine Diphenylb u­ ylpiperidin e Dihydroindolone Thioxanthene 300-600 15-30 75-100 2-15 + ++++ + ++ + Molindone Thiothixene Risperidone Moban Navane 50-100 30-40 2-8 10 5 1-2 +++ ++++ ++ ++ + + + ++ +++ + +++ ++ + + +++ Risperdal Benzisox­ azole .5 1 ++++ ++ ++++ +++ ++++ Muscarinic Effect Alpha-1 Adrenergic Blocking Effect + ++++ ++ +++ + Antihis tamine Effect + ++++ ++ ++++ + Serotone rgic Effect ++ ++++ +++ ++++ Haloperidol Clozapine Aripiprazole Loxapine Pimozide Haldol Clozaril Abilify Loxitane Orap Butyrophe.Name Trade name Class Average Dose (mg) ChlorproDopaminermazine gic Equivalents Effect (D2) (mg) 2 60 2-4 12.

Name Trade name Class Average Dose (mg) ChlorproDopaminermazine gic Equivalents Effect (D2) (mg) 3 +++ Muscarinic Effect Alpha-1 Adrenergic Blocking Effect ++ Antihis tamine Effect ++ Serotone rgic Effect +++ Olanzapine Zyprexa Zydis Thienobe n­ zodiazepin e 5-20 ++ Quetiapine Ziprasidone Seroquel Dibenzoth iazepine Geodon Benzisothi­ azolyl pip­ erzine 400-600 80-160 50 5-10 + +++ 0 + ++ + ++ + ++ +++ .

the oral antipsychotic can be discontinued. Long-acting risperidone is expected to be approved in late 2003. Thorazine is usually given 25-50 mg IM with close monitoring of blood pressure. For example. Atypical agents have a relatively low incidence of extrapyramidal effects. The dose may be reduced by 25% in each of the nexttwo monthsuntil the maintenance dose is 200 mg every 30 days. 1. produce a higher incidence ofanticholinergic side effects. B. tardive dyskinesias. Short-actingIMformulations ofziprasidone and olanzapine are available. Route of Administration A. Haldol 5-10 mg is often given in conjunction with 1-2 mg of IM Ativan. produce a high incidence of extrapyramidal symptoms such as acute dystonic reactions. 4. Once a patient has received one or two injections. such as risperidone (Consta). The recommended dose of IM ziprasidone is 10 mg every 2 hours or 20 mg every 4 hours as required up to a maximum daily dosage of 40 mg. which provides sedation. a patient receiving 20 mg of oral haloperidol per day would be given 400 mg of decanoate.IV. B. and anticholinergic side effects.suchashaloperidol and fluphenazine. Haldol. neuroleptic malignant syndrome. C. Oral formulations are available for all antipsychotics and some are available in liquid or orallydisintegrating form for elderly patients or to increase compliance in patients who “cheek” their medications and later spit them out. Prolixin decanoate should be started at 25 mg IM every two weeks with the dose adjusted up to 50 mg every two weeks if necessary. Low-potencyagents.suchaschlorpromazine. Parkinsonian syndrome. divided intothreeorfour IMinjections given over a seven-day period. High-potencyagents. A. sedation and orthostatic hypotension compared to high-potency agents such as haloperidol. Haloperidol (Haldol) and chlorpromazine (Thorazine) are often used in IM form to treatacutelyagitated psychotic patients. Long-acting intramuscular (depot) neuroleptics. Haldol decanoate shouldbestarted at twenty times the daily oral dose in the first month of treatment.and Prolixin decanoate are useful for non-compliant patients. . V.and akathisia. Antipsychotic Side Effects The following discussion is applicable primarily to the typical antipsychotics. 3. 2.

Dystonic reactions are most frequentlyinduced byhigh-potency neuroleptics such as haloperidol and fluphenazine (Prolixin). dryflushed skin.the dose of neuroleptic may need decreasing. Neuroleptics. such as chlorpromazine and thioridazine. These involuntary movements occur due to blockade of dopamine receptors in the nigrostriatal pathway of the basal ganglia. c. blurry vision. and can occurin young. . b. requiring urgentintravenous administration of diphenhydramine. Extrapyramidal Side Effects (EPS) 1. 2. tongue. E. eyes (oculogyric crisis).C. constipation. Patients withParkinsoniansyndrome secondarytoneuroleptics present with cogwheel rigidity.and high-potency agents. Dystonias are often very painful and frightening to patients. Drug-Induced Parkinsonian Syndrome a. Acute Dystonia a. bradykinesia.Laryngeal spasms can cause airway obstruction. d. jaw and other muscle groups. 2. Dystonias will often improve with a change to a lower potency or atypical agent. dilated pupils and elevated heart rate. In severe cases. Anticholinergic Side Effects 1.and shuffling gait. anticholinergic blockade can produce a central anticholinergic syndrome characterized byconfusion or delirium. Moderate-potency agents include trifluoperazine and thiothixene and have side effect profiles in between the low. otherwise healthy persons (particularly younger men) even after a single dose. Subsequently. 3. and urinary retention. mask-like facies.produce antichoinergic l side effects such as dry mouth. induce involuntary movements known as extrapyramidal side effects. especiallylow-potency agents. This is similar to patients withidiopathic Parkinson’s disease. Acute dystonic reactions are sustained contraction of the muscles of neck (torticollis). D. such ashaloperidol.Dystonias(otherthan laryngospasm) should be treated with 1-2 mg of benztropine (Cogentin) IM. Neuroleptics.especialythe high-potency agents. typically occurring within 10-14 days after initiation ofthe neuroleptic. The patient may require long-term anticholinergic medication to control the dystonia.

5. F. Most patients have relatively mild cases. which are manifest by difficulty remaining still and excessive walking or pacing. Patients who require continued neuroleptic therapy should be switched to an atypical agent or clozapine (if severe). with the exception of clozapine. produce tardive dyskinesia. grimaces and spastic facial distortions.Drug-induced Parkinsonism istreatedbyadding an anticholinergic agentsuchasbenztropine (Cogentin) or trihexyphenidyl (Artane). All neuroleptics. When tardive dyskinesia symptoms are observed. 6. Akathisia is characterized by strong feelingsofinner restlessness. Antiparkinsonian drugs are of no benefit for tardive dyskinesias and may exacerbate symptoms. fingers.b. .a beta-blocker such as propranolol is required in the dose range of 10-40 mg tid or qid. 4.butmoreoften. All neuroleptics. Tardive Dyskinesia (TD) 1. blinking. but tardive dyskinesia can be debilitating in severe cases. NMS is a rare idiosyncratic reaction. tongue protrusion. and other body parts. Tardive dyskinesias do not always improve with discontinuation or lowering of the dose of neuroleptic. 4. 3. 2. 7. which can be fatal. and there is an incidence of 3% per year with typical agents. Akathisia a. is also effective. sucking movements. b. The dopamine releasing agent. d. Tardive dyskinesia is an involuntary movement disorder involving the tongue.Akathisia may respond to the addition of an anticholinergic agent. toes.Parkinsonian symptoms may also improve with a lower dose of neuroleptic or after switching to a low-potency agent such as thioridazine or an atypical agent. The risk of tardive dyskinesia increases with the duration of neuroleptic exposure. Neuroleptic Malignant Syndrome (NMS) 1. Tardive dyskinesias are characterized bychewing movements. G. the offending drug should be discontinued. smacking and licking of the lips. mouth. amantadine. The risk of tardive dyskinesia withatypicalantipsychotics is substantiallydecreased compared to typical agents. Benzodiazepines such as diazepam are used for refractory cases. c.

The risk of NMS with atypical antipsychotics is substantially decreased. mesoridazine. but this effect does not appear to be clinically significant. WeightGain. Orthostatic Hypotension. K. M. The IM form of ziprasidone does not have this effect on the QT interval. and liver transaminases. and dantrolene. Blockade oftheserotonin 2C and histamine receptors may result in weight gain. compared to high-potency agents. such as haloperidol. or pimozide. bromocriptine.suchaschlorpromazine. Thioridazine hasthe greatesteffecton QTprolongation and should be used with caution. Neuroleptic sedation is related to blockade of H-1 histamine receptors. altered mental status. It is more common with low-potencyagents.thioridazine or clozapine. A fasting glucose and lipid profile should be obtained every 3-6 months for patients on atypical antipsychotics. H. may produce NMS. Cardiac conduction delays can occur with thioridazine. Antipsychotics may produce a wide range of sexual dysfunction. 2. Patients may require treatment in an intensive care unit. fever. Some atypical antipsychotics are associated with marked elevation of lipids and blood glucose. Sedation. 2. Sexual Side Effects 1. Alpha-1 adrenergic blockade results in orthostatic hypotension which may be serious and can lead tofalls and injury.with the exception of clozapine. 3. galactorrhea. which can result from treatment with clozapine and olanzapine. I. 2. along with supportive treatment and medications such as amantadine. Hyperlipidemiaand DiabetesMellitus 1. Ziprasidone may increase the QT interval. Laboratory tests often reveal an elevated WBC. Dopamine receptor (D2) blockade can lead to elevation of prolactin with subsequent gynecomastia. CPK. . J. NMS is characterized by severe muscle rigidity.Bedtimeadministration will often reduce daytime sedation. Patients should be advised to get up slowly from recumbent positions. and autonomic instability. Treatment involves discontinuing the neuroleptic immediately. L. Some data suggests these adverse effects are more common with clozapine and olanzapine and infrequent with ziprasidone.Orthostatic hypotension is especially common with low-potency agents such as chlorpromazine.and menstrual dysfunction. Cardiac Toxicity.

Treatment should include switchingto anotherclassofantipsychotic drug after a drug-free interval. Eosinophilia (>4000/mm3) may be a precursor of leukopenia. When white blood cell counts drop below 3 x 1012/liter. B. Cholestatic jaundice is usuallyreversible after discontinuation of the medication. Irreversible blindness can rarely occur with a dose of thioridazine greater than 800 mg per day. VI. 2. There is no significant elevation of prolactin or subsequent side effects. Fatigue and sedation are the most common side effects. 4. the incidence of EPS increases significantly. Clozapine is unique in that it does notproduce extrapyramidal symptoms. other neuroleptics. rarely. 1. Clozapine is associated with a 1% incidence of agranulocytosis. Clozapine (Clozaril)is a dibenzodiazepine derivative and is considered an atypical antipsychotic agent. Cholestaticjaundiceisararehypersensitivity reaction that is most common with chlorpromazine. respiratory arrest in conjunction with benzodiazepines. Retrograde ejaculation. Atypical Neuroleptics A. Patients should be advised to use sunscreen. O.Weeklymonitoring of the WBC is recommended for the first six months of treatment and every two weeks thereafter. Clozapine causessedation.and inhibition of orgasm are also common side effects. followed .orthostatic hypotension.3. At doses above 6 mg per day. Retinitis Pigmentosa. Antipsychotic agents often cause photosensitivity and a predisposition to sunburn. The effective dosage range is 2-8 mg/day. tardive dyskinesia. Risperidone (Risperdal) 1. excess salivation (sialorrhea). Photosensitivity is especially common with low-potency agents. such as chlorpromazine. Photosensitivity. 2. Most cases develop during the third and fourth weeks of treatment. erectile dysfunction. Clozapine is used for the treatment of patients who have not responded to. or cannot tolerate. N. and. clozapine must be discontinued.weightgain. The risk of seizures are increased at dosages above 600 mg per day. P. which can be fatal. or NMS. 3.tachycardia. Risperidone has an atypicalside-effect profile with minimal extrapyramidal symptoms at lower doses (up to 4-6 mg). Clozapine should be interrupted until count is below 3000/mm3.

abdominal pain. Most common side effects include drowsiness. These patients should have a baseline ECG. which is titrated every 1 or 2 days to a total daily dose of 400-600 mg (given bid or tid). leadingtogynecomastia. There isno evidence ofhemotoxicity. Initial dose is 25-50 mg bid. Sustained prolactin elevation is not observed. Risperidone can elevate prolactin. E. Prolactin elevation can occur. Olanzapine (Zyprexa) 1. The effective dose range is 5-20 mg/day. Olanzapine has an atypical side-effect profile with a very low incidence of extrapyramidal symptoms. 3. Dizziness. Dyspepsia. 2. nausea. The incidence of tardive dyskinesia is low.by weight gain and orthostatic hypotension. Olanzapinelevelsmaybedecreased bytobacco use or carbamazepine. and insomnia. Quetiapine (Seroquel) 1. and postural hypotension are the most common side effects. While there are no reports linking this to cardiac arrhythmias. 3. Dosage should be reduced in the elderly. Quetiapine is an atypical neuroleptic with a very low incidence of EPS. The typical starting dose is 10 mg/day. 4.galactorrhea and disruption of the menstrual cycle. C.orthostatic hypotension. or effects on lipids and glucose. D. Side effects include orthostatic hypotension. 2.weight gain. Ziprasidone IM (Geodon IM) is available and can be given 10 mg q 2-4 hours or 20 mg q 4 . Initial and periodic eye exams (with slit lamp) are recommended because of the occurrence of cataracts in very high dose animal studies. caution should be exercised in patients with pre-existing increased QT interval (from medications or cardiac disease). The effective dose range isbetween 40-80 mg bid. nausea. Ziprasidone has an atypical side effectprofile witha verylowincidence ofextrapyramidal symptoms. Agranulocytosis has not been reported. akathisia. No titration isrequired. dry mouth. 2. Ziprasidone can increase QT interval. 3. although some patients mayrequire higher doses. and tremor. Ziprasidone (Geodon) 1. somnolence. Less frequent side effectsinclude weightgain. Dose reductions should be made in the elderly. and dry mouth may also occur. and weightgain.

hours. Anticholinergics are drugs of choice for acute dystonias and for drug­ induced Parkinsonism. Aripiprazole has an atypical side effect profilewithaverylowincidence of extrapyramidal symptoms. Indications 1. and akathisia.Aripiprazole is expected to be available in 2003 or 2004. F. Somnolence is more common with the IM form. 3. VII. giving it a uniquemechanismofaction. Anticholinergic and antiparkinsonian agentsareusedtocontroltheextrapyramidal side effects of antipsychotic agents. QT prolongation has not been observed with the IM formulation. The anticholinergic agent should be tapered and discontinued after one to six months if possible. Classification of Anticholinergic/Antiparkinsonian Agents Name Benztropi ne Biperiden Trade Name Cogentin Akineton Class Anticholin­ ergic Anticholin­ ergic Anticholin­ ergic Antihista­ mine/ Anti­ cholinergic Dopamine/ Agonist Dose 1-2 mg bid-tid orally or 1-2 mg IM 2 mg bid-tid orally or 2 mg IM 2-5 mg bid-qid 25-50 mg bid to qid or 25­ 50 mg IM 100-150 mg bid Trihexy­ phenidyl Diphenhy dramine Amantadi ne Artane Benadryl Symmetrel . Antiparkinsonian agents are usually initiated when a patient develops neuroleptic-related extrapyramidal side effects. B. not to exceed 40 mg/day. Aripiprazole (Abilify) 1. This agent is a dopamine autoreceptor agonist and post-synaptic D2 receptor antagonist. 2. Aripiprazole has a low incidence of weight gain and no effect on QT interval.Intramuscular injections of anticholinergic agents are most effective for rapid relief. Anticholinergic and Antiparkinsonian Agents A. 2. but they may be given prophylactically in high-risk patients. neuroleptic induced Parkinsonism. Anticholinergic agents are less effective for drug-induced akathisia. including acute dystonic reactions. which often requires addition of a beta-blocker. Effective dose is 15-30 mg po per day.

4. Side Effects of Anticholinergic Agents a. The most common side effects resultfrom peripheral antichoinergic l blockade:drymouth,constipation, blurry vision, urinaryhesitancy, decreased sweating, increased heart rate, and ejaculatory dysfunction. b. Acentral anticholinergic syndrome occurs with high doses, or when the agent is combined wthotheranticholinergicmedications. i The syndrome is characterized by confusion, dry flushed skin, tachycardia,and pupillarydilation. In severe cases, delirium, hallucinations, arrhythmias, hypotension, seizures, and coma may develop. c. Anicholinergicdrugsarecontraindicated t in narrow angle glaucoma and should be used cautiously in prostatic hypertrophy or cardiovascular disease. d. Amantadine does not have anticholinergic side effects; however, amantadine may causenausea,insomnia,decreased concentration,dizziness, irritability, anxiety,and ataxia.Amantadine is contraindicated in renal failure. Antidepressants Indications forAntidepressant Medication. Unipolar and bipolar depression, organic mood disorders, anxietydisorders (panic disorder, generalized anxiety disorder, obsessive-compulsive disorder, social phobia), schizoaffective disorder, eating disorder, and impulse control disorders. II. Classification of Antidepressants A. Selective-Serotonin (5HT) Reuptake Inhibitors. Fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), citalopram (Celexa), escitalopram (Lexapro). B. Serotonin/Norepinephrine Reuptake Inhibitors. Heterocyclics (TCAs), venlafaxine (Effexor) C. Norepinephrine/Dopamine Reuptake Inhibitors. Bupropion (Wellbutrin). D. MixedSerotoninReuptakeInhibitor/Serotonin Receptor Antagonist. Trazodone (Desyrel), nefazodone (Serzone). E. Alpha-2 Adrenergic Antagonist. Mirtazapine (Remeron) F. Monamine Oxidase (MAO)Inhibitors. Phenelzine,tranylcypromine,isocarboxazid. III. Clinical Use of Antidepressants A. All antidepressants have been shown to have equivalent efficacy. The selection of an agent depends on past history of response, anticipated I.

tolerance to side effects, and coexisting medical problems. B. Once a therapeutic dose is reached, symptom improvementtypicallyrequires 3 to 6 weeks. TCAs and bupropion have the narrowest therapeutic index and presentthegreatestrisk in overdose. C. If no significant improvement is seen after an adequate trial (4-6 weeks), then the dosage should be increased or one may switch to a medication in another antidepressant class. Alternatively, an augmenting agent such as lithium should be added. D. When psychoticsymptoms accompany severe cases ofdepression,concomitant antipsychotic medication is usually required and should be discontinued when the psychosis abates. E. Patients with three episodes of major depression should be placed on long-term maintenance treatment. IV. Side Effects A. Cardiac Toxicity 1. Tricyclic antidepressants may slow cardiac conduction, resulting in intraventricular conduction delay, prolongation of the QT interval, and AVblock.Patients withpreexisting conduction problemsarepredisposed to arrhythmias. Therefore, TCAs should not be used in patients withconduction defects, arrhythmias, or a history of a recent MI. 2. SSRIs, venlafaxine, bupropion, mirtazapine, and nefazodone have noeffectsoncardiacconduction. B. Anticholinergic Adverse Drug Reactions. Dry mouth, blurred vision, constipation, and urinary retention. C. Antihistaminergic Adverse Drug Reactions. Sedation, weight gain. D. Adverse Drug Reactions Caused by Alpha-1 Blockade. Orthostatic hypotension,sedation,sexual dysfunction. E. Serotonergic Activation.GI symptoms (nausea,diarrhea),insomniaorsomnolence, agitation, tremor, anorexia, headache, and sexual dysfunction can occur withSSRIs,especiallyearlyin treatment. F. MAO inhibitors. The most common adverse drug reaction is hypotension. Patients are also at risk for hypertensive crisis if foods high in tyramine content or sympathomimetic drugs areconsumed. Despite the infrequent use of MAO inhibitors, they remain very important forthetreatmentofrefractorydepression.

Commonly Used Antidepressants Drug Recommended dosage Comments

Secondary Amine Tricyclics Class as a whole: Side effects include anticholinergic effects (dry mouth, blurred vision, constipation) and alpha-blocking effects (sedation, orthostatic hypotension, cardiac rhythm disturbances). May lower seizure threshold. Desipramine(Norpramin, Initial dosage 25-50 mg qhs, generics) average dose 150-250 mg/d, Mayrequire dose of 300 mg/d. [10, 25, 50, 75, 100, 150 mg] Protriptyline(Vivactil) Mayhave CNS stimulant effect; best taken in morning to avoid insomnia.

Initialdoseof5mgqam increasing Low sedation, avoid bedtime to 15-40 mg/d in bid dosing dosing. [5, 10 mg] Initial dose 25 mg qhs, increasing Sedating. to 75-150 mg/d; monitor levels to achieve serum level between 50-150 ng/mL. [10, 25, 50, 75 mg]

Nortriptyline(Pamelor)

Tertiary Amine Tricyclics Class as a whole: Anticholinergic effects and orthostatic hypotension may be more severe than with secondary amine tricyclics. All are contraindicated in glaucoma and should be used with caution in urinary retention and cardiovascular disorders. Amitriptyline (Elavil, Initial dose of 25-50 mg qhs generics) increasing to 150-250 mg/d. May be given as single hs dose. [10, 25, 50, 75, 100, 150 mg] CIomipramine(Anafranil) High sedation.Highanticholinergic activity.

Initial dose of 25-50 mg qhs Relativelyhighsedation,anticholinergic increasing to 150-250 mg/d; activity, and seizure risk. may be given once qhs [25, 50, 75 mg] High sedation, often used as a hypnotic at a dosage of 25-150 mg qhs. Relatively high sedation. Also used to treat enuresis.

Doxepin (Sinequan, Initial dose of 25-50 mg/d, Adapin) increasing to 150-300 mg/d. [10, 25, 50, 75, 100, 150 mg] Imipramine (Tofranil, 75 mg/d in a single dose qhs, generics) increasing to 150 mg/d; max 300 mg/d. [10, 25, 50 mg] Tetracyclic Mirtazapine(Remeron)

15 mg qhs initially increasing Highly sedating with average to 30-45 mg qhs over days of 2 kg weight gain in six weeks. to weeks [15, 30 mg] Minimaleffectonhepatic enzymes. Sedating. Substantial risk of seizures; maculopapular rash in 3-10%.

Maprotiline (Ludiomil, 75 mg qhs initially, Usual generics) effective dose 150 mg/d, max 225 mg/d. [25, 50, 75 mg]

150. increasing as needed Minimal sedation. Fluoxetine(Prozac) 10-20 mg/d initially. 20. galactorrhea. Paxil 20 mg hs initially. 150. 75. dry mouth. dizziness.Elderlystarting dosage. insomnia. 100 mg bid initially increasing Wellbutrin SR) to 100 mg tid over 5 days. Agitation. increasing to 150 mg bid over 4-7 days [75. Common sideeffects: Nausea. anorexia. Minimal sedation. [25. Mild hypertension. 20 mg tablets / 5 mg/mL soln] Fluvoxamine(Luvox) May be activating. then increase Moderate sedation.5-75 mg/day increasing to 150-225 mg/day [25. 150. or inhibition of hepatic enzymes. insomnia. Slow release (SR): begin with 100-150 mg qd for 3 days. 30. dry mouth. sexual dysfunction. 40 mg] Citalopram(Celexa) Escitalopram(Lexapro) Sertraline (Zoloft) 20-60 mg/d [20.5 mg bid initiallyincreasing (Effexor.50.5. [100. syndrome. tremor. Effexor XR) to 150-225 mg/day in divided dose. Longest half-life of any antidepressant (2-9days). 37. taken in AM. anxiety. postural 200. 100 mg] [XR: 37. 250 mg] hypotension. minimal sexual side-effects or inhibition of hepatic enzymes. blurred to 150-300 mg bid. . 50. activation. mg] Miscellaneous Nefazodone(Serzone) 50-100 mgbidinitially. 100] Bupropion (Wellbutrin.somnolence. or inhibition of hepaticenzymes. 40 mg] 10-20 mg qd 50 qd. 100.Discontinue 2months before pregnancy. 50. headache. headache. anxiety. 10 mg/d [10. Significant up to 300 mg/day [25. Max 600 mg/d. mild sedation. insomnia. nausea. Significant inhibition of CYP2D6. Maybe associated with tardive increase to 200-300 mg/d dyskinesia. constipation. neurolepticmalignant if necessary. Significant inhibition of CYP2D6 50 mg hs initially. activation. 300 sedating. Extended release (XR): 37. 150 mg] Selective-Serotonin Reuptake Inhibitors (SSRIs) Class as a whole: Common side effects include sexual dysfunction. may require up to 80 mg/day for OCD and bulimia [10. 100 or inhibition ofhepatic enzymes. 200 mg] Trazodone(Desyrel) 50-100 mg qhs initially increasing Rare association with priapism. nausea. 75. increasing Headache. Minimal or no inhibition ofhepaticenzymes. Significantinhibition ofCYP2D6. drymouth. to max of 200 mg/d [50. Highly mg/day [50. Venlafaxine 37. 100 mg] [SR: 100. vision somnolence. inhibition of CYP1A2 100 mg] Moderate sedation and dry mouth. max of CR [extendedrelease]) 80 mg/d. Good choice if sexual side effects from other agents. vomiting. headache.Drug Amoxapine(Asendin) Recommended dosage Comments Initial dosage 25-50 mg qhs. activation. Minimal sedation.5. gradually to dose of 300-600 Orthostatic hypotension. Paroxetine (Paxil. 100.

Serum levels.schizoaffective disorder. lithium is less effective than valproate (Depakote) in rapid cycling mania. However. B. dementia.Theaverage doseisbetween 1500-3000 mg/day. C. Mood stabilizers are the drugs of choice for bipolar disorder. Lithium(Eskalith. Valproic acid has become the mood stabilizer of choice due to its favorable side-effect profile and lower toxicity in overdose compared to lithium or carbamazepine. C.Mood Stabilizers I. Valproic acid is effective for bipolar disorder. They are effective for acute mania and for prophylaxis of mania and depression in bipolar disorders. Valproic Acid (Depakote) A. Depakote ER (extended release) tablets (500 mg) allow for once a day dosing. Mood stabilizers are less effective for bipolar depression. 4. This roughly corresponds to 500 mg tid or 750 bid with titration up to a serum level of 50-125 mg/mL. CBC. II. Regular and slow-release forms of lithium carbonate are available and either form may be given twice daily initially switching to once daily dosing after several weeks. schizoaffective disorder.in addition to being an antimanic agent. mental retardation and aggressive behavior. B. Valproate usually requires two weeks to take full effect. or mental retardation. 3.Divalproex is initiated at a dosage of 20 :g/kg for rapid stabilization of mania. It is also used for impulse control disorders and aggression in Cluster B personality disorders. and PT/PTT should be obtained weekly during the first month of treatment. Indications for Mood Stabilizers A. Lithonate) A. 2. Steady state levels can be measured in 2-3 days. Healthy young adults can usually tolerate300-600 mg of lithium carbonate. Elderly patients require doses of approximatelyhalf that of younger adults. Depakote ER has 80-90% bioavailabilitycompared to Depakote. Divalproex (Depakote) is the best toleratedformofvalproate. and cyclothymia. B.Eskalith CR. Valproic acid is more effective in rapid cycling and mixed state episode bipolar disorder than lithium. III. platelet count. but a trial of four to six weeks should be completed before evaluating efficacy. These agents are sometimes effective for impulse control disorders. . D. Treatment Guidelines 1. Lithium. possesses modest but significant antidepressant properties. and cyclothymia.

TSH. fasting blood sugar. Toxicity may occur when a patient becomes ill and ceases to eat and drink normally. A reduction of lithium dose may be required.finetremor. Nonsteroidal anti-inflammatory drugs. D.creatinine. Tremor is most common in the hands.20 mEq/L (0. free T4 levels. Diabetes insipidus may result from lithium administration. G. The dose is increased over seven to ten days until the plasma level is 0. Gastrointestinal distress(diarrhea. are initiated. 2. thirst. Serum lithium levels are measured 12 hours after the preceding dose of lithium. edema. Laboratoryevaluation prior to beginning treatment with lithium should include blood urea nitrogen.mild nausea (especially if the drug is not taken with food). or a single daily dose of lithium. such as chlorothiazide (Diuril). confusion. slow-release formulations. L. A reduction of lithium dose may be required. Tremor is treated bylowering the dosage or byadding low-dose propranolol (10-40 mg tid-qid). . Lithium levels should be carefully monitored. I. and diarrhea. Two weeks are required for effect. such as tremor. but continues to take lithium.andarrhythmias. Serum levels should be kept between 0. A patient who cannot eat and drink normally should temporarily discontinue lithium.ataxia. E. Serum levels must be drawn weekly for the first one to two months. Lithium levels rise 20-25 percent when diuretics. The usual adult dosage ranges from 600-2400 mg/day. J.Treatment consists of amiloride administration.8-1. Lithium toxicityis manifest bycoarse tremor. slurred speech.2 mMol/L K.Itpresents withpolyuria and polydipsia. elevate the plasma lithium level.seizures. Side effects. F.stupor. and the drug should be continued for four to eight weeks before evaluating efficacy.80-1. Side Effects 1. Serumcreatinine and TSH are monitored every 6 months. and an ECG in patients over 40 years or with pre-existing cardiac disease.80 to 1. Common side effects of lithium include polyuria.electrolytes. then every two to four weeks.persistent headache.twice daily at the start of therapy. 3. nausea) may be reduced by giving the medication with meals or by switching to a sustained release preparation. may be reduced by using divided doses. weight gain. H.20 mMol/L). vomiting.incontinence. such as ibuprofen or aspirin and ACE inhibitors.

Pretreatment Evaluations. Carbamazepine requires two weeks to take effect. Toxicity presents with emesis. C. IV. confusion. Carbamazepine induces its own metabolism and carbamazepine levels will decline between three and eight weeks. 4.000 cells/mcL. Hypothyroidism may result from lithium andis treated withlevothyroxine. . Carbamazepine (Tegretol) A. CBC with differential and platelets. Elevated WBC count. liver function tests and electrolytes weekly for a month. 4. usually between 11-15thousand.whichrequirediscontinuation of lithium. which usuallyresponds to discontinuation of lithium. EKG. 5.Treatmentofoverdose may require hemodialysis. but a therapeutic trial should last at least four to eight weeks. The most serious side effects ofcarbamazepineare agranulocytosis and aplastic anemia. or if the platelet count drops below 100.000.electrolytes.isfrequently observed and requires no treatment. liver function tests. Carbamazepine shouldbediscontinued if the total WBC count drops below 3.000 mcL.5 mEq/liter.500 cells/mcL. 7. Obtain serum levels (target is 8-12 :g/mL) along with a CBC. creatinine and physical examination. 3. 6. Cardiac side effects include T-wave flattening or inversion and rare arrhythmias. At this time. The WBC should be monitored more frequently if the white count begins to drop. 2.in doses of 5-20 mg per day with frequent monitoring of lithium and potassium levels. diarrhea.orifthe absolute neutrophil count drops below 1. the dosage mayneed tobeincreased to maintain a therapeutic blood level of 8-12 :g/mL. and cardiac arrhythmias. 2.5 mEq/liter. Lithium can induce or exacerbate psoriasis. which can be controlled with benzoyl peroxide or topical antibiotics. ataxia. Seizures.Carbamazepine is dosed bid or tid to minimize side effects. Lithium toxicity may occur when levels exceed 1. B. After the first month. coma and death may occur at levels above 2. levels may be drawn less frequently. Dermatological side effects include acne. 8. Side Effects 1. 5. Carbamazepine is used in patients whodonotrespondtolithium. Treatment Guidelines 1. which occur at a frequency of 1 in 20.

theophylline. warfarin. Stevens-Johnson syndrome.Thrombocyopenia t israreand mayrequire discontinuation of the drug if levels drop below 100. Elevation of serum ammonia is a rare complication and is often benign. 5.Hepatitis andpancreatitis are rarecomplications and usually occur during the first several months. phenytoin. however. 4.cyclosporine. Carbamazepine may also cause ataxia. If this occurs the carbamazepine dose should be decreased to achieve serum levels of 8-12 :g/mL.Stevens-Johnson syndrome begins with widespread purpuric macules. Valproateismore benign in overdose than lithium or carbamazepine. E. PT/PTT. is a rare side effectofcarbamazepine and requires immediatediscontinuation oftherapy. and these symptoms often improve with coadministration with food or after switching to an enteric coated preparation such as Depakote. thyroid supplements.antipsychotics. 2. corticosteroids. CBC. Elevated ammonia may.000. Physical examination. Gastrointestinal distress (nausea and vomiting) is the most common side effect. Pretreatment Evaluation. liver function tests. epidermis and severe constitutional symptoms. a severe dermatologic condition. Serum levelsare decreased byclomipramine and phenytoin. 6. be an indicator of severe l hepatotoxicity. benzodiazepines. Mild elevations of liver function occur in many patients and require no special treatmentexceptfrequent l monitoringofiverenzy mes. Carbamazepine is more benign in overdose than lithium. Sedation is common and usually abatesinthefirstfewweeks. and tremors (usually with high doses or toxicity). Mild elevations in liver function tests are seen in most patients and this does not require discontinuation of the drug.3.doxycycline. confusion. Hepatitis may rarely occur. 3. which may require discontinuation of carbamazepine. leading to epidermolysis necrosis with erosion of mucus membranes. Side Effects 1. platelets.oral contraceptives. 4. 5. Carbamazepine decreases serum levels ofacetaminophen.methadone. and ethosuximide. . valproate. D.especialyifaccompanied by confusion.

V. the time between doses should not exceed 12 hours. nauseaand vomiting and dizziness. fatigue. Impaired renal function is nota contraindication togabapentin. Serum levels are not useful because no therapeutic window has been established. Gabapentin has been reported to rarely cause anxiety. B. Clinical experience suggests that it may be effective in the treatment of manic and depressive episodes. Lamotrigine may be effective in the treatment of manic and depressive episodes. C. 3. . VI. Lamotrigine is an anticonvulsant. the dosage should be reduced in patients with impaired renal function. ataxia. irritability. It also appears to be more effective in the treatment of depression compared to other mood stabilizers. B. Starting dose is 300 mg q day with titration up to an average daily dose of 900-1800 mg q day in divided doses. A small number of controlled studies support its effectiveness in mood disorders. Given its short half-life. Therapeutic effects can be seen in 2-4 weeks. 2. A small number of controlled studies support the effectiveness of gabapentin in mood disorders. agitation and depression. D. however. It appears to have some efficacy for mixed episodes and rapid cycling. The most common side effects are somnolence. Treatment Guidelines 1. Gabapentin has been effective primarily as an adjunctive treatment to other mood stabilizers and/or antidepressants. Some studies have used up to 3600 mg/day. Lamotrigine (Lamictal) A. Renal function should be evaluated before initiating treatment because gabapentin is excreted unchanged renally. Side Effects 1. prompting some clinicians to use it in the treatment of resistant unipolar depression. Weight gain is an occasional side effect of gabapentin. Gabapentin (Neurontin) A. 2.

C. Lamotrigine has been successful as monotherapy and as adjunctive treatment to other mood stabilizers and/or antidepressants. It appears to be effective for mixed episodes and rapid cycling. D. Treatment Guidelines 1. Pre-treatment evaluation should include an assessment of renal and hepatic function because both are involved in its excretion. 2. The initial dosage is 25 mg qd, increased weekly to 50 mg/day, 100 mg/day, then 200 mg/day. Up to 400 mg may be required to treat depression. Dosing can be either once or twice a day. 3. Serum levelsare notuseful because the therapeutic window has not been determined. 4. Coadministrationwithotheraniconvulsants t can affect serum levels and should be used with caution. 5. Therapeutic effect may be seen in 2-4 weeks. E. Side Effects 1. The most common side effects are dizziness, sedation, headache, diplopia,ataxiaordecreasedcoordination. The side effect most likelyto cause discontinuation of the drug is rash (10%), which can be quite severe. Rashismostcommonwhenlamotrigine is initiated at higher doses when titration is rapid. 2. Lamotrigine has been reported to cause irritability, agitation, anxiety, mania and depression. 3. Carbamazepinewill lower lamotrigine levels and valproate will increase lamotrigine levels. VII. Topiramate (Topamax) A. Topiramate is a new anticonvulsant that is being studied for efficacy as a mood stabilizer. Uncontrolled studies indicate that topiramate may have efficacy in the treatment of mixed mania and rapid cycling thatis unresponsive to valproate or carbamazepine. B. Treatment Guidelines 1. The starting dose is 25-50 mg/day, increasing at increments of 25-50 mg per week to a target dose of 200-400 mg/day, given in single dose or bid. Therapeutic effects are seen in 2-4 weeks.

2. Topiramate is primarily excreted unchanged in urine and has no effect on liver enzymes. Plasma levels oftopiramate can be reduced up to 50% when combined with carbamazepine and to a lesser degree with valproate. Topiramate can reduce clearance of phenytoin and impair the efficacy of oral contraceptives. C. Side Effects 1. The most common side effects are sedation, dizziness, ataxia, vision problems, speech problems, memoryimpairment, and problems with language processing. 2. Unlike other mood stabilizers, topiramate does not cause weight gain and may promote weight loss. VIII. Tiagabine (Gabitril) A. Tiagabine is a new anticonvulsant that is being studied for efficacy as a mood stabilizer. Uncontrolled studies suggest that it may be useful as an adjunct to other mood stabilizers. Tiagabine may have some efficacy for chronic pain and anxiety. B. Tiagabine is hepaticallymetabolized, but it does not appear to induce hepatic enzymes. Tiagabine does not affect the metabolism of other medications. Clearance may be decreased up to60%whencombinedwithcarbamazepine, phenytoin, or phenobarbital. C. The initial dose is 4 mg/day, increasing by 4 mg at weekly intervals to 12 mg/day, given in single dose or bid. The typical maintenance dose for seizures is 24-32 mg/day given bid or qid. D. The most common side effects are dizziness, lack of energy, somnolence, nausea, nervousness, and tremor. IX. Oxcarbazepine (Trileptal) A. Oxcarbazepine isa newanticonvulsant that is being studied for efficacy as a mood stabilizer. Controlled studies suggest that it is effective in mania at doses between 900-2400 mg/day. B. The most common side effects are somnolence, dizziness, diplopia, ataxia, nausea, vomiting and rash.

X. Levetiracetam(Keppra)has beenapproved for treatment of partial seizures. Its efficacy for affective illness is unknown. Antimanic Agents Name Divalproex sodium Trade Name Depakote Dosage Forms 125, 250 or 500 mg 125 mg sprinkle cap­ sules Lithium car­ bonate Lithium car­ bonate, slow release Lithium ci­ trate Carbamaze­ pine Lithonate, Eskalith Lithobid, Eskalith CR Cibalith-S Tegretol, generics 300 mg 300 or 450 mg 8 mEq/5 mL 100 or 200 mg Liquid: 100 mg/5 mL Valproic acid Divalproex sodium ex­ tended re­ lease Gabapentin Lamotrigine Tiagabine Topiramate Depakene Depakote ER 250 mg 500 mg Dose Range 500-4000 mg in bid dosing 500-3000 mg in bid dosing 600-2400 mg 600-2400 mg Therapeutic Drug Levels 50-125 micro­ gm/mL 50-125 micro­ gm/mL 0.8-1.2 mEq/liter 0.8-1.2 mEq/liter

10-40 mL 400-1800 mg in bid- qid dosing 400-1800 mg in bid- qid dosing 500-3000 mg in bid dosing 500-4000 mg in a single dose 300-800 mg tid 100-400 mg 12-mg qd or in divided dose 200-400 mg qd or in di­ vided dose

0.8-1.2 mEq/liter 8-12 micro­ gm/mL 8-12 micro­ gm/mL 50-125 micro­ gm/mL 50-125 mcg/mL

Neurontin Lamictal Gabitril Topamax

100, 300, 400 mg 25, 100, 150, 200 mg 4, 12, 16, 20 mg 25, 100, 200 mg

not applicable not applicable not applicable not applicable

Allbenzodiazepines induce tolerance and are addictive. especially in combination with alcohol or respiratory disorders. The 3-hydroxy-benzodiazepines (lorazepam. 2 mg IM because it is well tolerated and effective in most patients. 3. 1. b. insomnia. Benzodiazepines are contraindicated in pregnancy or lactation.25-2 tid/qid 25-50 tid/qid 6-20 30-100 . Respiratorydepression can occur athigh doses. Benzodiazepines A.5 10 Half-Life of Metabolites (hours) Alprazolam Chlordiazep­ oxide Xanax Librium 0. 2. 2. such as chronic obstructive pulmonary disease. the drug should be tapered slowly.Anterograde amnesiaiscommonafterbenzodiazepine use.are preferable for long-term treatment because they cause less withdrawal and require less frequent dosing. Tolerance to sedative effects often occurs during the first few weeks of treatment. oxazepam) have no active metabolites and are the agents of choice in patients with impaired liver function. Acute agitation usually is treated with lorazepam (Ativan). Indications. slurred speech. seizure disorders. When benzodiazepines are discontinued. Benzodiazepines may produce ataxia. Sedation is the most common anduniversalsideeffectofbenzodiazepines. Antianxiety Agents Name Trade Name Dose (mg) Dose Equivalence 0. Short courses of treatment should be used whenever possible. Side Effects 1. CognitiveDysfunction. The primaryindications for long-term treatmentare chronic anxietydisorders such as generalized anxietydisorder and panicdisorder.Antianxiety Agents I. Benzodiazepines are used for the treatmentofanxietydisorders. and dizziness.suchasclonazepam and diazepam . 3. They are also effective adjunctive agents for agitated psychotic or depressive states. Miscellaneous Side Effects a. and alcohol detoxification. Long-acting agents.alprazolam. especially with high-potency agents (alprazolam) or short-acting agents (triazolam). B.

the most common side effects are nausea. headaches.5 -30 bid 2-15 bid/tid 20-80 bid 0.25 7. 2. The starting dose is 5 mg two to three times a day. Dosage 1.Graduallyincrease to a maximum dosage of 60 mg per day over several weeks.5–2 tid/qid 15-30 tid/qid 5-20 bid/tid 18-50 30-100 30-100 30-100 10-20 8-12 30-100 II. 2. Buspirone is not addicting and has no withdrawal syndrome or tolerance. Buspirone (BuSpar) is indicated foranxietydisorders.Name Trade Name Dose (mg) Dose Equivalence 0.25-2 bid/tid 7. Electroconvulsive Therapy . At least two weeks are required before clinical improvement occurs. References References. B.such as generaized l anxiety disorder. It does not produce sedation or potentiate the effects of alcohol. Buspirone may also be an effective adjunctive agent in the treatment resistant depression. C. Many patients respond to a total dose of 30-40 mg per dayin two to three divided doses. dizziness. Buspirone is a nonbenzodiazepine anxiolytic agent of the azaperone class. see page 121. Side Effects 1. Indications 1. Buspirone is generallywell tolerated. and insomnia.5 5 20 1 15 10 Half-Life of Metabolites (hours) Clonazepam Clorazepate Diazepam Halazepam Lorazepam Oxazepam Prazepam Klonopin Tranxene Valium Paxipam Ativan Serax Centrax 0. Buspirone maybe added in a dosage of 15-60 mg/dayifa patienthas had a suboptimal response to a 3-6 week trial of an antidepressant. Buspirone (BuSpar) A. D. 2.

spinal X-ray series.urinalysis. not involved in the treatment of the patient. electrolytes. EKG. wait one minute and then stimulate again.Electroconvulsive therapy (ECT) is a highly effective treatment for depression. Electroconvulsive therapy may be usedasafirst-linetreatmentfor depression. After an airway has been established. 3. catatonic stupor. oxygen content. Electroconvulsive therapy is effective for major depressive disorder. and who want to avoid long-term fetal exposure to antidepressant medication. C. B. and the electroencephalogram should be monitored. A second psychiatrist. with a response rate of 90%. Informed consent should be obtained 24 hours prior to the first treatment. D. B. 2. liver enzymes. D. Pregnant women who are severely depressed. is administered for anesthesia. can safely undergo ETC. must also examine the patient and document the appropriateness of ECT and the patient's abilityto give informed consent. Electroconvulsive TherapyProcedure 1. 4. chest X-ray. A short-acting barbiturate. C. Indications A. Depression in Parkinson's disease responds to ECT with the added benefit of improvement of the movement disorder. a rubber mouth block is then placed and an electrical stimulus is applied to induce the seizure. compared to a 70% response rate for antidepressants. thyroid function). If theseizurelastsless than 25 seconds. routine laboratorytests (CBC. Electroconvulsive TherapyEvaluation A. Electrical stimulation should . The seizure must last a minimum of 25 seconds and should not last longer than two minutes. The duration ofthe seizure is monitored byEEGand byobservingtheisolated extremity. such as methohexital. Pretreatment evaluation should include a complete a history and physical. A tourniquet (to prevent paralysis) is applied to one extremity in order to monitor the motor component of the seizure. I. and acute psychosis. Muscle paralysis is then induced by succinylcholine. bipolar affective disorder (to treat mania and depression). II. and brain CT scan. The patient should be NPO for at least eight hours and blood pressure. especially if associated with acute suicidal behavior or psychotic symptoms. Dose 1. cardiac activity. Elderly patients tend to have a better response to ECT than toantidepressant medication.

com/ccs . If seizures exceed two minutes. The first three are often performed with bilateral electrode placement. Loss of recent memory usuallyresolves within a few days to a few weeks. maintenance ECT may be required for up to six months after the end of the initial series of 8-12 treatments. The prognosis is similar to that of major depression. A minimum of six treatments are usuallyrequired (common course is8-12 treatments). 1994. Washington. B. MemoryLoss.C. IV. Treatments are given weekly for one month and then graduallytapered to one treatment every four to five weeks. 3. Additional references may be obtained at www. Infrequently. Headache is common after ECT. B.. ContraindicationstoElectroconvulsive Therapy include intracranial mass. 2. Treatments are given two to three times per week. and it usually resolves with analgesics in a few hours. References American Psychiatric Association. D. American Psychiatric Association. III. Some patients may require long-term treatment. intravenous diazepam is used to terminate the seizure.ccspublishing. Maintenance Electroconvulsive Therapy A.be discontinued after three failed attempts. V. and the complication rate is comparable to that of anesthesia alone. A small numberofpatients complain ofpersistent memorydifficulties after several months. Side Effects of Electroconvulsive Therapy A. recentstroke. 4th edition.and recent MI. Diagnostic and Statistical Manual of Mental Disorders.Retrograde and anterograde amnesia of the events surrounding the treatment is common. The procedure is very safe. Up to twenty treatments may be necessarybefore maximum response is attained.

Hypnotic.. or Anxio­ lytic Dependence 305.01 Predominantly Hyperactive-Impulsive Type DEMENTIA 290.50 Opioid Abuse SEDATIVE-.00 Alcohol Abuse 291. With Late Onset (also code 331.40 Amphetamine Dependence 305. or Anxio­ lytic Abuse POLYSUBSTANCE-RELATED DISORDER 304.xx Dementia of the Alzheimer's Type. [Indicate the General Medical Condition] ALCOHOL-RELATED DISORDERS 303.01 Combined Type .10 Sedative.90 Alcohol Dependence 305.xx Attention-Deficit/Hyperactivity Disorder .xx Vascular Dementia . OR ANXIOLYTIC-RELATED DISORDERS 304.0 Alzheimer's disease on Axis III) .10 Uncomplicated 290.40 Uncomplicated MENTAL DISORDERS DUE TO A GENERAL MEDICAL CONDITION NOT ELSEWHERE CLASSIFIED 310. HYPNOTIC-.60 Cocaine Abuse OPIOID-RELATED DISORDERS 304..80 Polysubstance Dependence .1 Personality Change Due to.0 Alzheimer's disease on Axis III) .8 Alcohol-Induced Anxiety Dis­ order AMPHETAMINE (OR AMPHETAMINE-LIKE)-RELATED DISORDERS 304.40 Sedative. With Early Onset (also code 331.00 Predominantly Inattentive Type .8 Alcohol-Induced Mood Disor­ der 291.20 Cocaine Dependence 305. Hypnotic.xx Dementia of the Alzheimer's Type.Selected DSM-IV Codes ATTENTION-DEFICIT AND DISRUPTIVE BEHAVIOR DISORDERS 314.0 Uncomplicated 290.70 Amphetamine Abuse COCAINE-RELATED DISORDERS 304.00 Opioid Dependence 305.

xx Bipolar I Disorder.81 Posttraumatic Stress Disorder 308.xx Psychotic Disorder Due to.10 Disorganized Type .4 Dysthymic Disorder 311 Depressive Disorder NOS BIPOLAR DISORDERS 296.8 Brief Psychotic Disorder 297.22 Agoraphobia Without History of Panic Disorder 300.50 Eating Disorder NOS ADJUSTMENT DISORDERS 309.6x Most Recent Episode Mixed .40 Schizophreniform Disorder 295...3 Acute Stress Disorder 300.1 Delusional Disorder 298.21 Panic Disorder With Agora­ phobia 300.xx Major Depressive Disorder .4x Most Recent Episode Manic .0 With Depressed Mood .0x Single Manic Episode .30 Paranoid Type . .60 Residual Type 295.1 Anorexia Nervosa 307.51 Bulimia Nervosa 307.23 Social Phobia 300.02 Generalized Anxiety Disorder EATING DISORDERS 307.3 Obsessive-Compulsive Disor­ der 309.80 Bipolar Disorder NOS 293.xx Schizophrenia .5x Most Recent Episode Depressed .81 With Delusions . .70 Schizoaffective Disorder 297.SCHIZOPHRENIA AND OTHER PSYCHIATRIC DISORDERS 295..82 With Hallucinations 298.40 Most Recent Episode Hypomanic .01 Panic Disorder Without Ago­ raphobia 300.13 Cyclothymic Disorder 296..90 Undifferentiated Type .2x Single Episode . [Indicate the General Medical Condition] ANXIETY DISORDERS 300.29 Specific Phobia 300.9 Psychotic Disorder NOS DEPRESSIVE DISORDERS 296.83 Mood Disorder Due to.3 Shared Psychotic Disorder 293.7 Most Recent Episode Un­ specified 296.3x Recurrent 300.89 Bipolar II Disorder 301.20 Catatonic Type .xx Adjustment Disorder .

82 Avoidant Personality Disorder 301.50 Histrionic Personality Disor­ der 301.83 Borderline Personality Disor­ der 301.9 With Anxiety With Mixed Anxiety and Depressed Mood With Disturbance of Con­ duct With Mixed Disturbance of Emotions and Conduct Unspecified PERSONALITY DISORDERS 301.9 Personality Disorder NOS .7 Antisocial Personality Disor­ der 301.4 Obsessive-Compulsive Per­ sonality Disorder 301.20 Schizoid Personality Disorder 301.24 .6 Dependent Personality Disor­ der 301.81 Narcissistic Personality Disor­ der 301.0 Paranoid Personality Disorder 301.4 .3 ..22 Schizotypal Personality Disor­ der 301.28 .

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