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FOCUSED LEARNING for the
psychiatry clerkship
Tips on what to know to IMPRESS

ATTENDINGS and EARN HONORS
on the shelf exam
Completely UPDATED
FOR THE DSM-5
FIRST AID FOR
THE®
PSYCHIATRY
CLERKSHIP
FOURTH EDITION
LATHA GANTI, MD, MS, MBA, FACEP Sean M. Blitzstein, MD

Director, VACO Southeast Specialty Care Director, Psychiatry Clerkship
Center of Innovation Clinical Associate Professor of Psychiatry
Orlando VA Medical Center University of Illinois at Chicago
Professor of Emergency Medicine Chicago, Illinois
University of Central Florida
Orlando, Florida
MATTHEW S. KAUFMAN, MD
Associate Director
Department of Emergency Medicine
Richmond University Medical Center
New York, New York
New York / Chicago / San Francisco / Athens / Lisbon / London / Madrid / Mexico City
Milan / New Delhi / Singapore / Sydney / Toronto
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CONTENTS
Contributing Authors v
Introduction vii
Chapter 1: How to Succeed in the Psychiatry Clerkship 1
Chapter 2: Examination and Diagnosis 11
Chapter 3: Psychotic Disorders 21
Chapter 4: Mood Disorders 33
Chapter 5: Anxiety, Obsessive-Compulsive, Trauma, and Stressor-Related Disorders 47
Chapter 6: Personality Disorders 63
Chapter 7: Substance-Related and Addictive Disorders 79
Chapter 8: Neurocognitive Disorders 97
Chapter 9: Geriatric Psychiatry 113
Chapter 10: Psychiatric Disorders in Children 121
Chapter 11: Dissociative Disorders 133
Chapter 12: Somatic Symptom and Factitious Disorders 139
Chapter 13: Impulse Control Disorders 145
Chapter 14: Eating Disorders 151
Chapter 15: Sleep-Wake Disorders 159
Chapter 16: Sexual Dysfunctions and Paraphilic Disorders 171
Chapter 17: Psychotherapies 179
Chapter 18: Psychopharmacology 189
Chapter 19: Forensic Psychiatry 209
Index 217
iii
CONTRIBUTING AUTHORS
Sean M. Blitzstein, MD Kelley A. Volpe, MD
Director, Psychiatry Clerkship Chief Resident, Department of Psychiatry
Clinical Associate Professor of Psychiatry University of Illinois at Chicago College of Medicine
University of Illinois at Chicago Chicago, Illinois
Chicago, Illinois Eating Disorders
Examination and Diagnosis Sleep-Wake Disorders
Personality Disorders Psychotherapies
Substance-Related and Addictive Disorders Forensic Psychiatry
Geriatric Psychiatry
Somatic Symptom and Factitious Disorders
Sexual Dysfunctions and Paraphilic Disorders Alexander Yuen, MD
Resident, Department of Psychiatry
University of Illinois at Chicago
Amber C. May, MD Chicago, Illinois
Resident, Department of Psychiatry Psychotic Disorders
University of Illinois at Chicago Mood Disorders
Chicago, Illinois Impulse Control Disorders
Anxiety, Obsessive-Compulsive, Trauma and Stressor-Related Disorders Psychopharmacology
Neurocognitive Disorders
Psychiatric Disorders in Children
Dissociative Disorders
v
INTRODUCTION
This clinical study aid was designed in the tradition of the First Aid series of
books. It is formatted in the same way as the other books in this series; how-
ever, a stronger clinical emphasis was placed on its content in relation to psy-
chiatry. You will find that rather than simply preparing you for success on the
clerkship exam, this resource will help guide you in the clinical diagnosis and
treatment of many problems seen by psychiatrists.
Each of the chapters in this book contains the major topics central to the
practice of psychiatry and has been specifically designed for the medical stu-
dent learning level. It contains information that psychiatry clerks are expected
to learn and will ultimately be responsible for on their shelf exams.
The content of the text is organized in the format similar to other texts in the
First Aid series. Topics are listed by bold headings, and the “meat” of the top-
ics provides essential information. The outside margins contain mnemonics,
diagrams, exam and ward tips, summary or warning statements, and other
memory aids. Exam tips are marked by the icon, tips for the wards by the
icon, and clinical scenarios by the icon.
vii
Chapter 1
How to Succeed in the

Psychiatry Clerkship
Why Spend Time on Psychiatry? 2 Keep Patient Information Handy 3
How to Behave on the Wards 2 Present Patient Information in an Organized Manner 3
Respect the Patients 2 How to Prepare for the Clerkship (Shelf ) Exam 4
Respect the Field of Psychiatry 2 Study with Friends 4
Take Responsibility for Your Patients 3 Study in a Bright Room 4
Respect Patients’ Rights 3 Eat Light, Balanced Meals 4
Volunteer 3 Take Practice Exams 4
Be a Team Player 3 Pocket Cards 5
1
2 Chapter 1 HOW TO SUCCEED IN THE PSYCHIATRY CLERKSHIP
The psychiatry clerkship will most likely be very interesting and exciting.
A key to doing well in this clerkship is finding the balance between drawing
a firm boundary of professionalism with your patients and creating a relation-
ship of trust and comfort.
Why Spend Time on Psychiatry?

For most, your medical school psychiatry clerkship will encompass the
entirety of your formal training in psychiatry during your career in medicine.
Being aware of and understanding the features of mental dysfunction in psy-

chiatric patients will serve you well in recognizing psychiatric symptoms in
your patients, regardless of your specialty choice.
While anxiety and depression can worsen the prognosis of patients’ other
medical conditions, medical illnesses can cause significant psychological
stress, often uncovering a previously subclinical psychiatric condition. The
stress of extended hospitalizations can strain normal mental and emotional
functioning beyond their adaptive reserve, resulting in transient psychiatric
symptoms.
Psychotropic medications are frequently prescribed in the general popula-

tion. Many of these drugs have significant medical side effects and drug
interactions. You will become familiar with these during your clerkship
and will encounter them in clinical practice regardless of your field of
medicine.
Because of the unique opportunity to spend a great deal of time interacting

with your patients, the psychiatry clerkship is an excellent time to practice
your interview skills and “bedside manner.”
How to Behave on the Wards
R E S P E C T T H E PAT I E N T S
Always maintain professionalism and show the patients respect. Be respectful

when discussing cases with your residents and attendings.
R E S P E C T T H E F I E L D O F P S Y C H I AT R Y
■■ Regardless of your interest in psychiatry, take the rotation seriously.

■■ You may not agree with all the decisions that your residents and attendings
make, but it is important for everyone to be on the same page. Be aware of
patients who try to split you from your team.
■■ Dress in a professional, conservative manner.
■■ Working with psychiatric patients can often be emotionally taxing. Keep
yourself healthy.
■■ Psychiatry is a multidisciplinary field. It would behoove you to continu-
ously communicate with nurses, social workers, and psychologists.
■■ Address patients formally unless otherwise told.
HOW TO SUCCEED IN THE PSYCHIATRY CLERKSHIP Chapter 1 3
TA K E R E S P O N S I B I L I T Y F O R Y O U R PAT I E N T S
Know as much as possible about your patients: their history, psychiatric and
medical problems, test results, treatment plan, and prognosis. Keep your
intern or resident informed of new developments that they might not be
aware of, and ask them for any updates you might not be aware of. Assist the
team in developing a plan; speak to consultants and family members. Never
deliver bad news to patients or family members without the assistance of your
supervising resident or attending.
R E S P E C T PAT I E N T S ’ R I G H T S
1. All patients have the right to have their personal medical information kept
private. This means do not discuss the patient’s information with family
members without that patient’s consent, and do not discuss any patient in
public areas (e.g., hallways, elevators, cafeterias).
2. All patients have the right to refuse treatment. This means they can refuse
treatment by a specific individual (the medical student) or of a specific
type (no electroconvulsive therapy). Patients can even refuse lifesaving
treatment. The only exceptions to this rule are if the patient is deemed
to not have the capacity to make decisions or if the patient is suicidal or
homicidal.
3. All patients should be informed of the right to seek advance directives on
admission. Often, this is done by the admissions staff or by a social worker.
If your patient is chronically ill or has a life-threatening illness, address
the subject of advance directives with the assistance of your resident or
attending.
VOLUNTEER
Be enthusiastic and self-motivated. Volunteer to help with a procedure or a

difficult task. Volunteer to give a 20-minute talk on a topic of your choice, to
take additional patients, and to stay late.
BE A TEAM PLAYER
Help other medical students with their tasks; teach them information you
have learned. Support your supervising intern or resident whenever possible.
Never steal the spotlight or make a fellow medical student look bad.
K E E P PAT I E N T I N F O R M AT I O N H A N D Y
Use a clipboard, notebook, or index cards to keep patient information, includ-

ing a history and physical, lab, and test results, at hand.
P R E S E N T PAT I E N T I N F O R M AT I O N I N A N O R G A N I Z E D M A N N E R
Here is a template for the “bullet” presentation:
“This is a [age]-year-old [gender] with a history of [major history such

as bipolar disorder] who presented on [date] with [major symptoms,
such as auditory hallucinations] and was found to have [working diag-
nosis]. [Tests done] showed [results]. Yesterday, the patient [state impor-
tant changes, new plan, new tests, new medications]. This morning the
patient feels [state the patient’s words], and the mental status and physi-
cal exams are significant for [state major findings]. Plan is [state plan].”
The newly admitted patient generally deserves a longer presentation following

the complete history and physical format.
Many patients have extensive histories. The complete history should be pres-
ent in the admission note, but during ward presentations, the entire history
is often too much to absorb. In these cases, it will be very important that you
generate a good summary that is concise but maintains an accurate picture of
the patient.
How to Prepare for the Clerkship (Shelf ) Exam

If you have studied the core psychiatric symptoms and illnesses, you will know
a great deal about psychiatry. To specifically study for the clerkship or shelf
exam, we recommend:
2–3 weeks before exam: Read this entire review book, taking notes.
10 days before exam: Read the notes you took during the rotation and the
corresponding review book sections.
5 days before exam: Read this entire review book, concentrating on lists and
mnemonics.
2 days before exam: Exercise, eat well, skim the book, and go to bed early.
1 day before exam: Exercise, eat well, review your notes and the mnemonics,
and go to bed on time. Do not have any caffeine after 2 pm.
Other helpful studying strategies include:
STUDY WITH FRIENDS
Group studying can be very helpful. Other people may point out areas that
you have not studied enough and may help you focus more effectively. If you
tend to get distracted by other people in the room, limit this amount to less
than half of your study time.
STUDY IN A BRIGHT ROOM
Find the room in your home or library that has the brightest light. This will
help prevent you from falling asleep. If you don’t have a bright light, obtain a
halogen desk lamp or a light that simulates sunlight.
E AT L I G H T, B A L A N C E D M E A L S
Make sure your meals are balanced, with lean protein, fruits and vegetables,
and fiber. A high-sugar, high-carbohydrate meal will give you an initial burst
of energy for 1–2 hours, but then your blood sugar will quickly drop.
TA K E P R A C T I C E E X A M S
The purpose of practice exams is not just for the content that is contained in
the questions, but the process of sitting for several hours and attempting to
choose the best answer for each and every question.
POCKET CARDS
The “cards” on the following page contain information that is often helpful in
psychiatry practice. We advise that you make a photocopy of these cards, cut
them out, and carry them in your coat pocket.
Mental Status Exam
Appearance/Behavior: apparent age, attitude and cooperativeness, eye

contact, posture, dress and hygiene, psychomotor status
Speech: rate, rhythm, volume, tone, articulation
Mood: patient’s subjective emotional state—depressed, anxious, sad,

angry, etc.
Affect: objective emotional expression—euthymic, dysphoric, euphoric,

appropriate (to stated mood), labile, full, constricted, flat, etc.
Thought process: logical/linear, circumstantial, tangential, flight of

ideas, looseness of association, thought blocking
Thought content: suicidal/homicidal ideation, delusions, preoccupa-

tions, hyperreligiosity
Perceptual disturbances: hallucinations, illusions, derealization, deper-

sonalization
Cognition:
Level of consciousness: alert, sleepy, lethargic
Orientation: person, place, date
Attention/concentration: serial 7s, spell “world” backwards
Memory:
Registration: immediate recall of three objects
Short term: recall of objects after 5 minutes
Long term: ask about verifiable personal information
Fund of knowledge: current events
Abstract thought: interpretation of proverbs, analogies
Insight: patient’s awareness of his/her illness and need for treatment
Judgment: patient’s ability to approach his/her problems in an appropri-

ate manner
Delirium
Characteristics: acute onset, waxing/waning sensorium (worse at night),

disorientation, inattention, impaired cognition, disorganized thinking,
altered sleep-wake cycle, perceptual disorders (hallucinations, illusions)
(continued)
Etiology: drugs (narcotics, benzodiazepines, anticholinergics, TCAs, ste-

roids, diphenhydramine, etc.), EtOH withdrawal, metabolic (cardiac,
respiratory, renal, hepatic, endocrine), infection, neurological causes
(increased ICP, encephalitis, postictal, stroke)
Investigations:
Routine: CBC, electrolytes, glucose, renal panel, LFTs, TFTs, UA,
urine toxicology, CXR, O2 sat, HIV
Medium-yield: ABG, ECG (silent MI), ionized Ca2+
If above inconclusive: Head CT/MRI, EEG, LP
Management: identify/correct underlying cause, simplify Rx regi-

men, d/c potentially offensive medications if possible, avoid benzo-
diazepines (except in EtOH withdrawal), create safe environment,
provide reassurance/education, judiciously use antipsychotics for acute
agitation
Mini-Mental State Examination (MMSE)
Orientation (10):
What is the [year] [season] [date] [day] [month]? (1 pt. each)

Where are we [state] [county] [town] [hospital] [floor]?
Registration (3): Ask the patient to repeat three unrelated objects (1 pt.
each on first attempt). If incomplete on first attempt, repeat up to six
times (record # of trials).
Attention (5): Either serial 7s or “world” backwards (1 pt. for each

correct letter or number).
Delayed recall (3): Ask patient to recall the three objects previously
named (1 pt. each).
Language (9):
■■ Name two common objects, e.g., watch, pen (1 pt. each).
■■ Repeat the following sentence: “No ifs, ands, or buts” (1 pt.).
■■ Give patient blank paper. “Take it in your right hand, use both hands
to fold it in half, and then put it on the floor” (1 pt. for each part
correctly executed).
■■ Have patient read and follow: “Close your eyes” (1 pt.).
■■ Ask patient to write a sentence. The sentence must contain a
subject and a verb; correct grammar and punctuation are not
necessary (1 pt.)
■■ Ask the patient to copy the design. Each figure must have five sides,
and two of the angles must intersect (1 pt.).
Mania (“DIG FAST”)
Distractibility
Irritable mood/insomnia
Grandiosity
Flight of ideas
Agitation/increase in goal-directed activity
Speedy thoughts/speech
Thoughtlessness: seek pleasure without regard to consequences
Suicide Risk (“SAD PERSONS”)

Sex—male
Age >60 years
Depression
Previous attempt
Ethanol/drug abuse
Rational thinking loss
Suicide in family
Organized plan/access
No support
Sickness
Depression (“SIG E. CAPS”)

Sleep
Interest
Guilt
Energy
Concentration
Appetite
Psychomotor Ds
Suicidal ideation
Hopelessness
Helplessness
Worthlessness
Drugs of Abuse
Drug Intoxication Withdrawal

Alcohol Disinhibition, mood lability, Tremulousness,
Benzodiazepines incoordination, slurred hypertension, tachycardia,
speech, ataxia, blackouts anxiety, psychomotor
(EtOH), respiratory depression agitation, nausea, seizures,
hallucinations, DTs (EtOH)
Barbiturates Respiratory depression Anxiety, seizures,

delirium, life-threatening
cardiovascular collapse
(continued)
Opioids CNS depression, nausea, Increased sympathetic

vomiting, sedation, decreased activity, N/V, diarrhea,
pain perception, decreased diaphoresis, rhinorrhea,
GI motility, pupil constriction, piloerection, yawning,
respiratory depression stomach cramps, myalgias,
arthralgias, restlessness,
anxiety, anorexia
Amphetamines Euphoria, increased attention Post-use “crash”:

Cocaine span, aggressiveness, restlessness, headache,
psychomotor agitation, pupil hunger, severe depression,
dilatation, hypertension, irritability, insomnia/
tachycardia, cardiac hypersomnia, strong
arrhythmias, psychosis psychological craving
(paranoia with amphetamines,
formication with cocaine)
PCP Belligerence, impulsiveness, May have recurrence

psychomotor agitation, of symptoms due to
vertical/horizontal nystagmus, reabsorption in GI tract
hyperthermia, tachycardia,
ataxia, psychosis, homicidality
LSD Altered perceptual states

(hallucinations, distortions
of time and space), elevation
of mood, “bad trips” (panic
reaction), flashbacks
(reexperience of the
sensations in absence of
drug use)
Cannabis Euphoria, anxiety, paranoia,

slowed time, social
withdrawal, increased
appetite, dry mouth,
tachycardia, amotivational
syndrome
Nicotine/ Restlessness, insomnia, Irritability, lethargy,

Caffeine anxiety, anorexia headache, increased
appetite, weight gain
First Aid for the Psychiatry Clerkship, 4e; copyright © 2015 McGraw-Hill. All rights reserved.
Psychiatric Emergencies
Delirium Tremens (DTs):

■■ Typically within 2–4 days after cessation of EtOH but may occur
later.
■■ Delirium, agitation, fever, autonomic hyperactivity, auditory and
visual hallucinations.
■■ Treat aggressively with benzodiazepines and hydration.
Neuroleptic Malignant Syndrome (NMS):
■■ Fever, rigidity, autonomic instability, clouding of consciousness,
elevated WBC/CPK
■■ Withhold neuroleptics, hydrate, consider dantrolene and/or
bromocriptine
■■ Idiosyncratic, time-limited reaction
Serotonin Syndrome:
■■ Precipitated by use of two drugs with serotonin-enhancing properties
(e.g., MAOI + SSRI).
■■ Altered mental status, fever, agitation, tremor, myoclonus, hyperre-
flexia, ataxia, incoordination, diaphoresis, shivering, diarrhea.
■■ Discontinue offending agents, benzodiazepines, consider cyprohep-
tadine.
Tyramine Reaction/Hypertensive Crisis:
■■ Precipitated by ingestion of tyramine containing foods while on
MAOIs.
■■ Hypertension, headache, neck stiffness, sweating, nausea, vomiting,
visual problems. Most serious consequences are stroke and possibly
death.
■■ Treat with nitroprusside or phentolamine.
Acute Dystonia:
■■ Early, sudden onset of muscle spasm: eyes, tongue, jaw, neck; may
lead to laryngospasm requiring intubation.
■■ Treat with benztropine (Cogentin) or diphenhydramine (Benadryl).
Lithium Toxicity:
■■ May occur at any Li level (usually >1.5).
■■ Nausea, vomiting, slurred speech, ataxia, incoordination, myoclonus,
hyperreflexia, seizures, nephrogenic diabetes insipidus, delirium,
coma
■■ Discontinue Li, hydrate aggressively, consider hemodialysis
Tricyclic Antidepressant (TCA) Toxicity:
■■ Primarily anticholinergic effects; cardiac conduction disturbances,
hypotension, respiratory depression, agitation, hallucinations.
■■ CNS stimulation, depression, seizures.
■■ Monitor ECG, activated charcoal, cathartics, supportive treatment.
notes
Chapter 2
EXAMINATION AND DIAGNOSIS
History and Mental Status Examination 12 Diagnosis and Classification 18

Interviewing 12 Diagnosis as per DSM-5 18
Taking the History 13 Diagnostic Testing 18
Mental Status Examination 14 Intelligence Tests 18
Mini-Mental State Examination (MMSE) 17 Objective Personality Assessment Tests 19
Interviewing Skills 17 Projective (Personality) Assessment Tests 19
General Approaches to Types of Patients 17
11
12 Chapter 2 EXAMINATION AND DIAGNOSIS
History and Mental Status Examination
INTERVIEWING
Making the Patient Comfortable

The initial interview is of utmost importance to the psychiatrist. With prac-
WARDS TIP tice, you will develop your own style and learn how to adapt the interview to the
individual patient. In general, start the interview by asking open-ended ques-
The HPI should include information tions and carefully note how the patient responds, as this is critical infor-
about the current episode, including mation for the mental status exam. Consider preparing for the interview by
symptoms, duration, context, stressors, writing down the subheadings of the exam (see Figure 2-1). Find a safe and
and impairment in function. private area to conduct the interview. Use closed-ended questions to obtain the
remaining pertinent information. During the first interview, the psychiatrist
Date and Location:
Identifying Patient Data:
Chief Complaint: Past Medical History:
History of Present Illness:
Allergies:
Past Psychiatric History: Current Meds:
First contact:
Developmental History:
Diagnosis:
Prior hospitalizations:
Relationships (children/marital status):
Suicide attempts:
Outpatient treatment:
Education:
Med trials:
Work History:
Substance History: Military History:
Housing:
Smoking: Income:
Family Psychiatric History: Religion:
Legal History:
FIGURE 2-1. Psychiatric history outline.

EXAMINATION AND DIAGNOSIS Chapter 2 13
must establish a meaningful rapport with the patient in order to get accu-
rate and pertinent information. This requires that questions be asked in a WARDS TIP
quiet, comfortable setting so that the patient is at ease. The patient should
feel that the psychiatrist is interested, nonjudgmental, and compassionate. If you are seeing the patient in the ER,
In psychiatry, the history is the most important factor in formulating a diag- make sure to ask how they got to the
nosis and treatment plan. ER (police, bus, walk-in, family member)
and look to see what time they were
triaged. For all initial evaluations, ask
why the patient is seeking treatment
today as opposed to any other day.
TA K I N G T H E H I S T O R Y
The psychiatric history follows a similar format as the history for other types of
patients. It should include the following: WARDS TIP
■■ Identifying data: The patient’s name, gender, age, race, marital status,
place and type of residence, occupation. When taking a substance history,
■■ Chief complaint (use the patient’s own words). If called as a consultant, remember to ask about caffeine and
list reason for the consult. nicotine use. If a heavy smoker is
■■ Sources of information. hospitalized and does not have access
■■ History of present illness (HPI): to nicotine replacement therapy,
■■ The 4 Ps: The patient’s psychosocial and environmental conditions pre- nicotine withdrawal may cause anxiety
disposing to, precipitating, perpetuating, and protecting against the cur- and agitation.
rent episode.
■■ The patient’s support system (whom the patient lives with, distance and
level of contact with friends and relatives).

■■ Neurovegetative symptoms (quality of sleep, appetite, energy, psycho- KEY FACT
motor retardation/activation, concentration).
■■ Suicidal ideation/homicidal ideation. Importance of asking about OTC use:
■■ How work and relationship have been affected (for most diagnoses in Nonsteroidal anti-inflammatory drugs
the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (NSAIDs) can ↓ lithium excretion → ↑
[DSM-5] there is a criterion that specifies that symptoms must cause lithium concentrations (exceptions may
clinically significant distress or impairment in social, occupational, or be sulindac and aspirin).
other important areas of functioning).
■■ Psychotic symptoms (e.g., auditory and visual hallucinations).
■■ Establish a baseline of mental health:
■■ Patient’s level of functioning when “well” WARDS TIP

■■ Goals (outpatient setting)
■■ Past psychiatric history (include as applicable: history of suicide attempts, Psychomotor retardation, which
history of self-harm [e.g., cutting, burning oneself], information about pre- refers to the slowness of voluntary
vious episodes, other psychiatric disorders in remission, medication trials, and involuntary movements, may
past psychiatric hospitalizations, current psychiatrist). also be referred to as hypokinesia or
■■ Substance history (history of intravenous drug use, participation in outpa- bradykinesia. The term akinesia is used
tient or inpatient drug rehab programs). in extreme cases where absence of
■■ Medical history (ask specifically about head trauma, seizures, pregnancy status). movement is observed.
■■ Family psychiatric and medical history (include suicides and treatment
response as patient may respond similarly).
■■ Medications (ask about supplements and over-the-counter medications).
■■ Allergies: Clarify if it was a true allergy or an adverse drug event (e.g., KEY FACT
abdominal pain).
■■ Developmental history: Achieved developmental milestones on time, Automatisms are spontaneous,
friends in school, performance academically. involuntary movements that occur
■■ Social history: Include income source, employment, education, place of during an altered state of consciousness
residence, who they live with, number of children, support system, reli- and can range from purposeful to
gious affiliation and beliefs, legal history, amount of exercise, history of disorganized.
trauma or abuse.
M E N TA L S TAT U S E X A M I N AT I O N
WARDS TIP
This is analogous to performing a physical exam in other areas of medicine. It
A hallmark of pressured speech is
is the nuts and bolts of the psychiatric exam. It should describe the patient in
that it is usually uninterruptible and
as much detail as possible. The mental status exam assesses the following:
the patient is compelled to continue
speaking. ■■ Appearance
■■ Behavior
■■ Speech
■■ Mood/Affect
KEY FACT ■■ Thought Process
■■ Thought Content
An example of inappropriate affect is a ■■ Perceptual Disturbances
patient’s laughing when being told he ■■ Cognition
has a serious illness. ■■ Insight
■■ Judgment/Impulse Control
The mental status exam tells only about the mental status at that moment; it
can change every hour or every day, etc.
KEY FACT
You can roughly assess a patient’s

Appearance/Behavior
intellectual functioning by utilizing the ■■ Physical appearance: Gender, age (looks older/younger than stated age),
proverb interpretation and vocabulary type of clothing, hygiene (including smelling of alcohol, urine, feces),
strategies. Proverb interpretation is posture, grooming, physical abnormalities, tattoos, body piercings. Take
helpful in assessing whether a patient specific notice of the following, which may be clues for possible diagnoses:
has difficulty with abstraction. Being ■■ Pupil size: Drug intoxication/withdrawal.
able to define a particular vocabulary ■■ Bruises in hidden areas: ↑ suspicion for abuse.
word correctly and appropriately use ■■ Needle marks/tracks: Drug use.
it in a sentence reflects a person’s ■■ Eroding of tooth enamel: Eating disorders (from vomiting).
intellectual capacity. ■■ Superficial cuts on arms: Self-harm.
■■ Behavior and psychomotor activity: Attitude (cooperative, seductive, flat-

tering, charming, eager to please, entitled, controlling, uncooperative,
hostile, guarded, critical, antagonistic, childish), mannerisms, tics, eye
WARDS TIP contact, activity level, psychomotor retardation/activation, akathisia,
automatisms, catatonia, choreoathetoid movements, compulsions, dysto-
nias, tremor.
To assess mood, just ask, “How are you
feeling today?” It can also be helpful to
have patients rate their stated mood on Speech
a scale of 1–10. Rate (pressured, slowed, regular), rhythm (i.e., prosody), articulation (dysarthria,
stuttering), accent/dialect, volume/modulation (loudness or softness), tone,
long or short latency of speech.
WARDS TIP Mood

Mood is the emotion that the patient tells you he feels, often in quotations.
A patient who is laughing one second
and crying the next has a labile affect. Affect
Affect is an assessment of how the patient’s mood appears to the examiner,
including the amount and range of emotional expression. It is described with
the following dimensions:
WARDS TIP
■■ Type of affect: Euthymic, euphoric, neutral, dysphoric.
A patient who giggles while telling ■■ Quality/Range describes the depth and range of the feelings shown.
you that he set his house on fire and Parameters: flat (none)—blunted (shallow)—constricted (limited)—full
is facing criminal charges has an (average)—intense (more than normal).
inappropriate affect. ■■ Motility describes how quickly a person appears to shift emotional states.
Parameters: sluggish—supple—labile.
■■ Appropriateness to content describes whether the affect is congru-

ent with the subject of conversation or stated mood. Parameters: WARDS TIP
appropriate—not appropriate.
A patient who remains expressionless
and monotone even when discussing
Thought Process extremely sad or happy moments in his
The patient’s form of thinking—how he or she uses language and puts ideas life has a flat affect.
together. It describes whether the patient’s thoughts are logical, meaningful,
and goal directed. It does not comment on what the patient thinks, only how
the patient expresses his or her thoughts. Circumstantiality is when the point
of the conversation is eventually reached but with overinclusion of trivial or
irrelevant details. Examples of thought disorders include: KEY FACT
■■ Tangentiality: Point of conversation never reached; responses usually in
the ballpark. Examples of delusions:
■■ Loosening of associations: No logical connection from one thought to ■■ Grandeur—belief that one has
another. special powers or is someone
■■ Flight of ideas: Thoughts change abruptly from one idea to another, usu- important (Jesus, President)
ally accompanied by rapid/pressured speech. ■■ Paranoid—belief that one is being
■■ Neologisms: Made-up words. persecuted

■■ Word salad: Incoherent collection of words. ■■ Reference—belief that some event
■■ Clang associations: Word connections due to phonetics rather than actual is uniquely related to patient (e.g.,
meaning. “My car is red. I’ve been in bed. It hurts my head.” a TV show character is sending
■■ Thought blocking: Abrupt cessation of communication before the idea is patient messages)
finished. ■■ Thought broadcasting—belief that
one’s thoughts can be heard by

others
Thought Content ■■ Religious—conventional beliefs
Describes the types of ideas expressed by the patient. Examples of exaggerated (e.g., Jesus talks to me)
■■ Somatic—false belief concerning
disorders:
body image (e.g., I have cancer)
■■ Poverty of thought versus overabundance: Too few versus too many ideas
expressed.
■■ Delusions: Fixed, false beliefs that are not shared by the person’s culture
and cannot be changed by reasoning. Delusions are classified as bizarre
(impossible to be true) or nonbizarre (at least possible).
■■ Suicidal and homicidal ideation: Ask if the patient feels like harming WARDS TIP
him/herself or others. Identify if the plan is well formulated. Ask if the
patient has an intent (i.e., if released right now, would he go and kill him- The following question can help screen
self or harm others?). Ask if the patient has means to kill himself (firearms for compulsions: Do you clean, check,
in the house/multiple prescription bottles). or count things on a repetitive basis?
■■ Phobias: Persistent, irrational fears.
■■ Obsessions: Repetitive, intrusive thoughts.
■■ Compulsions: Repetitive behaviors (usually linked with obsessive thoughts).
Perceptual Disturbances WARDS TIP

■■ Hallucinations: Sensory perceptions that occur in the absence of an actual
stimulus. An auditory hallucination that instructs
■■ Describe the sensory modality: Auditory (most common), visual, taste, a patient to harm himself or others is
olfactory, or tactile. an important risk factor for suicide or
■■ Describe the details (e.g., auditory hallucinations may be ringing, homicide.
humming, whispers, or voices speaking clear words). Command
auditory hallucinations are voices that instruct the patient to do
something.
■■ Ask if the hallucination is experienced only before falling asleep
(hypnagogic hallucination) or upon awakening (hypnopompic hal

lucination).
■■ Illusions: Inaccurate perception of existing sensory stimuli (e.g., wall

appears as if it’s moving).
■■ Derealization/Depersonalization: The experience of feeling detached from
one’s surroundings/mental processes.
Sensorium and Cognition

Sensorium and cognition are assessed in the following ways:
■■ Consciousness: Patient’s level of awareness; possible range includes:
WARDS TIP Alert—drowsy—lethargic—stuporous—coma.
■■ Orientation: To person, place, and time.
Alcoholic hallucinosis refers to ■■ Calculation: Ability to add/subtract.
hallucinations (usually auditory, ■■ Memory:
■■ Immediate (registration)—dependent on attention/concentration and
although visual and tactile may occur)
that occur either during or after a can be tested by asking a patient to repeat several digits or words.
■■ Recent (short-term memory)—events within the past few minutes,
period of heavy alcohol consumption.
Patients usually are aware that these hours or days.
■■ Remote memory (long-term memory).
hallucinations are not real. In contrast
to delirium tremens (DTs), there is no ■■ Fund of knowledge: Level of knowledge in the context of the patient’s
clouding of sensorium and vital signs culture and education (e.g., Who is the president? Who was Picasso?).
are normal. ■■ Attention/Concentration: Ability to subtract serial 7s from 100 or to spell
“world” backwards.
■■ Reading/Writing: Simple sentences (must make sure the patient is literate
first).
■■ Abstract concepts: Ability to explain similarities between objects and
understand the meaning of simple proverbs.
Insight
Insight is the patient’s level of awareness and understanding of his or her
problem. Problems with insight include complete denial of illness or blaming
it on something else. Insight can be described as full, partial/limited, or none.
Judgment
Judgment is the patient’s ability to understand the outcome of his or her
actions and use this awareness in decision making. Best determined from
information from the HPI and recent behavior (e.g., how a patient was
brought to treatment or medication compliance). Judgment can be described
as excellent, good, fair, or poor.
Mrs. Gong is a 52-year-old Asian-American woman who arrives at

the emergency room reporting that her deceased husband of 25
years told her that he would be waiting for her there. In order to meet
him, she drove nonstop for 22 hours from a nearby state. She claims that
her husband is a famous preacher and that she, too, has a mission from
God. Although she does not specify the details of her mission, she says
that she was given the ability to stop time until her mission is completed.
She reports experiencing high levels of energy despite not sleeping for
22 hours. She also reports that she has a history of psychiatric hospital-
izations but refuses to provide further information.
While obtaining her history you perform a mental status exam. Her
appearance is that of a woman who looks older than her stated age.
She is obese and unkempt. There is no evidence of tattoos or piercings.
She has tousled hair and is dressed in a mismatched flowered skirt and
a red T-shirt. Upon her arrival at the emergency room, her behavior is
demanding, as she insists that you let her husband know that she has
arrived. She then becomes irate and proceeds to yell, banging her head
against the wall. She screams, “Stop hiding him from me!” She is unco-
operative with redirection and is guarded during the remainder of the
interview. Her eye contact is poor as she is looking around the room.
Her psychomotor activity is agitated. Her speech is loud and pressured,
with a foreign accent.
She reports that her mood is “angry,” and her affect as observed during
the interview is labile and irritable.
Her thought process includes flight of ideas. Her thought content is

significant for delusions of grandeur and thought broadcasting, as evi-
denced by her refusing to answer most questions claiming that you are
able to know what she is thinking. She denies suicidal or homicidal ide-
ation. She expresses disturbances in perception as she admits to fre-
quent auditory hallucinations of command.
She is uncooperative with formal cognitive testing, but you notice that
she is oriented to place and person. However, she erroneously states that
it is 2005. Her attention and concentration are notably impaired, as she
appears distracted and frequently needs questions repeated. Her insight,
judgment, and impulse control are determined to be poor.
You decide to admit Mrs. Gong to the inpatient psychiatric unit in order
to allow for comprehensive diagnostic evaluation, the opportunity to
obtain collateral information from her prior hospitalizations, safety mon-
itoring, medical workup for possible reversible causes of her symptoms,
and psychopharmacological treatment.
M I N I - M E N TA L S TAT E E X A M I N AT I O N ( M M S E )
The MMSE is a simple, brief test used to assess gross cognitive functioning.
See the Cognitive Disorders chapter for detailed description. The areas tested
include:
■■ Orientation (to person, place, and time).
■■ Memory (immediate—registering three words; and recent—recalling
three words 5 minutes later).
■■ Concentration and attention (serial 7s, spell “world” backwards).
■■ Language (naming, repetition, comprehension).
■■ Complex command.
■■ Visuospatial ability (copy of design).
Interviewing Skills
G E N E R A L A P P R O A C H E S T O T Y P E S O F PAT I E N T S
Violent Patient
One should avoid being alone with a potentially violent patient. Inform
staff of your whereabouts. Know if there are accessible panic buttons. To
assess violence or homicidality, one can simply ask, “Do you feel like you
want to hurt someone or that you might hurt someone?” If the patient
WARDS TIP expresses imminent threats against friends, family, or others, the doctor
should notify potential victims and/or protection agencies when appropri-
To test ability to abstract, ask: ate (Tarasoff rule).
1. Similarities: How are an apple and
orange alike? (Normal answer: “They
are fruits.” Concrete answer: “They are Delusional Patient
round.”) Although the psychiatrist should not directly challenge a delusion or insist
2. Proverb testing: What is meant by that it is untrue, he should not imply he believes it either. He should simply
the phrase, “You can’t judge a book acknowledge that he understands the patient believes the delusion is true.
by its cover?” (Normal answer: “You
can’t judge people just by how they
look.” Concrete answer: “Books have Depressed Patient
different covers.”) A depressed patient may be skeptical that he or she can be helped. It is impor-
tant to offer reassurance that he or she can improve with appropriate therapy.
Inquiring about suicidal thoughts is crucial; a feeling of hopelessness, sub-
stance use, and/or a history of prior suicide attempts reveal an ↑ risk for sui-
cide. If the patient is actively planning or contemplating suicide, he or she
should be hospitalized or otherwise protected.
KEY FACT
A prior history of violence is the most Diagnosis and Classification

important predictor of future violence.
DIAGNOSIS AS PER DSM-5
The American Psychiatric Association uses a criterion-based system for diag-

noses. Criteria and codes for each diagnosis are outlined in the DSM-5.
WARDS TIP
In assessing suicidality, do not simply

ask, “Do you want to hurt yourself?” Diagnostic Testing
because this does not directly address
suicidality (he may plan on dying in
a painless way). Ask directly about INTELLIGENCE TESTS
killing self or suicide. If contemplating
suicide, ask the patient if he has a plan Aspects of intelligence include memory, logical reasoning, ability to assimilate
of how to do it and if he has intent; a factual knowledge, understanding of abstract concepts, etc.
detailed plan, intent, and the means to
accomplish it suggest a serious threat. Intelligence Quotient (IQ)
IQ is a test of intelligence with a mean of 100 and a standard deviation of
15. These scores are adjusted for age. An IQ of 100 signifies that mental age
equals chronological age and corresponds to the 50th percentile in intellec-
tual ability for the general population.
KEY FACT
Intelligence tests assess cognitive function by evaluating comprehension, fund
of knowledge, math skills, vocabulary, picture assembly, and other verbal and
The Minnesota Multiphasic Personality
performance skills. Two common tests are:
Inventory (MMPI) is an objective
psychological test that is used to assess
Wechsler Adult Intelligence Scale (WAIS):
a person’s personality and identify
psychopathologies. The mean score ■■ Most common test for ages 16–90.
for each scale is 50 and the standard ■■ Assesses overall intellectual functioning.
deviation is 10. ■■ Four index scores: Verbal comprehension, perceptual reasoning, working
memory, processing speed.
Wechsler Intelligence Scale for Children (WISC): Tests intellectual ability in

patients ages 6–16. WARDS TIP
IQ Chart
OBJECTIVE PERSONALIT Y ASSESSMENT TESTS Very superior: >130
Superior: 120–129
These tests are questions with standardized-answer format that can be objec- High average: 110–119
tively scored. The following is an example: Average: 90–109
Low average: 80–89
Minnesota Multiphasic Personality Inventory (MMPI-2) Borderline: 70–79
■■ Tests personality for different pathologies and behavioral patterns. Extremely low (intellectual
■■ Most commonly used. disability): <70
PROJECTIVE (PERSONALIT Y) ASSESSMENT TESTS
Projective tests have no structured-response format. The tests often ask for
interpretation of ambiguous stimuli. Examples are:
Thematic Apperception Test (TAT)

■■ Test taker creates stories based on pictures of people in various situations.
■■ Used to evaluate motivations behind behaviors.
Rorschach Test
■■ Interpretation of inkblots.
■■ Used to identify thought disorders and defense mechanisms.
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Chapter 3
PSYCHOTIC DISORDERS
Psychosis 22 Pathophysiology of Schizophrenia: The Dopamine Hypothesis 26

Delusions 22 Other Neurotransmitter Abnormalities Implicated in Schizophrenia 27
Perceptual Disturbances 22 Prognostic Factors 27
Differential Diagnosis of Psychosis 22 Treatment 27
Psychotic Disorder Due to Another Medical Condition 23 Schizophreniform Disorder 29
Substance/Medication-Induced Psychotic Disorder 23
Schizoaffective Disorder 29
Schizophrenia 23
Brief Psychotic Disorder 30
Positive, Negative, and Cognitive Symptoms 24
Three Phases 24 Delusional Disorder 30
Diagnosis of Schizophrenia 24 Culture-Specific Psychoses 31
Psychiatric Exam of Patients with Schizophrenia 25
Comparing Time Courses and Prognoses of
Epidemiology 26
Psychotic Disorders 31
Downward Drift 26
Quick and Easy Distinguishing Features 31
21
22 Chapter 3 PSYCHOTIC DISORDERS
Psychosis
Psychosis is a general term used to describe a distorted perception of real-
WARDS TIP ity. Poor reality testing may be accompanied by delusions, perceptual distur-
bances (illusions or hallucinations), and/or disorganized thinking/ behavior.
Psychosis is exemplified by either Psychosis can be a symptom of schizophrenia, mania, depression, delirium,
delusions, hallucinations, or severe and dementia, and it can be substance or medication-induced.
disorganization of thought/behavior.
DELUSIONS
Delusions are fixed, false beliefs that remain despite evidence to the contrary
and cannot be accounted for by the cultural background of the individual.
They can be categorized as either bizarre or nonbizarre. A nonbizarre delu-

sion is a false belief that is plausible but is not true. Example: “The neighbors
are spying on me by reading my mail.” A bizarre delusion is a false belief that
is impossible. Example: “A Martian fathered my baby and inserted a micro-
chip in my brain.”
Delusions can also be categorized by theme:

■■ Delusions of persecution/paranoid delusions: Irrational belief that one is
being persecuted. Example: “The CIA is after me and tapped my phone.”
■■ Ideas of reference: Belief that cues in the external environment are
uniquely related to the individual. Example: “The TV characters are
speaking directly to me.”
■■ Delusions of control: Includes thought broadcasting (belief that one’s
thoughts can be heard by others) and thought insertion (belief that others’
thoughts are being placed in one’s head).
■■ Delusions of grandeur: Belief that one has special powers beyond those of
a normal person. Example: “I am the all-powerful son of God and I shall
bring down my wrath on you if I don’t get my way.”
■■ Delusions of guilt: Belief that one is guilty or responsible for something.
Example: “I am responsible for all the world’s wars.”
■■ Somatic delusions: Belief that one is infected with a disease or has a cer-
tain illness.
P e r c ep t u a l D is t u r b a n c es
■■ Illusion: Misinterpretation of an existing sensory stimulus (such as mistak-

ing a shadow for a cat).
■■ Hallucination: Sensory perception without an actual external stimulus.
WARDS TIP ■■ Auditory: Most commonly exhibited by schizophrenic patients.
■■ Visual: Occurs but less common in schizophrenia. May accompany

Auditory hallucinations that directly tell drug intoxication, drug and alcohol withdrawal, or delirium.
the patient to perform certain acts are ■■ Olfactory: Usually an aura associated with epilepsy.
called command hallucinations. ■■ Tactile: Usually secondary to drug use or alcohol withdrawal.
D i f f e r en t i a l D i a g nosis o f P s y c h osis
■■ Psychotic disorder due to another medical condition

■■ Substance/Medication-induced psychotic disorder
■■ Delirium/Dementia
■■ Bipolar disorder, manic/mixed episode
■■ Major depression with psychotic features
PSYCHOTIC DISORDERS Chapter 3 23
■■ Brief psychotic disorder

■■ Schizophrenia WARDS TIP
■■ Schizophreniform disorder
■■ Schizoaffective disorder It’s important to be able to distinguish
■■ Delusional disorder between a delusion, illusion, and
hallucination. A delusion is a false belief,
an illusion is a misinterpretation of an
P S YCH O T I C diso r de r due t o a no t h e r M edi c a l Condi t ion external stimulus, and a hallucination
is perception in the absence of an
Medical causes of psychosis include: external stimulus.
1. Central nervous system (CNS) disease (cerebrovascular disease, multiple
sclerosis, neoplasm, Alzheimer’s disease, Parkinson’s disease, Huntington’s
disease, tertiary syphilis, epilepsy [often temporal lobe], encephalitis, prion
disease, neurosarcoidosis, AIDS).
2. Endocrinopathies (Addison/Cushing disease, hyper/hypothyroidism, hyper/
hypocalcemia, hypopituitarism).
3. Nutritional/Vitamin deficiency states (B12, folate, niacin).
4. Other (connective tissue disease [systemic lupus erythematosus, temporal
arteritis], porphyria).
DSM-5 criteria for psychotic disorder due to another medical condition include:
■■ Prominent hallucinations or delusions. WARDS TIP
■■ Symptoms do not occur only during an episode of delirium.
■■ Evidence from history, physical, or lab data to support another medical Elderly, medically ill patients who
cause (i.e., not psychiatric). present with psychotic symptoms such
as hallucinations, confusion, or paranoia
should be carefully evaluated for
S u b s ta n c e / M edi c at ion - indu c ed ps y c h o t i c diso r de r
delirium, which is a far more common
finding in this population.
Prescription medications that may cause psychosis in some patients include
anesthetics, antimicrobials, corticosteroids, antiparkinsonian agents, anti-
convulsants, antihistamines, anticholingerics, antihypertensives, NSAIDs,
digitalis, methylphenidate, and chemotherapeutic agents. Substances such as
alcohol, cocaine, hallucinogens (LSD, Ecstasy), cannabis, benzodiazepines,
barbiturates, inhalants, and phencyclidine (PCP) can cause psychosis, either
in intoxication or withdrawal.
DSM-5 Criteria
WARDS TIP
■■ Hallucinations and/or delusions.
■■ Symptoms do not occur only during episode of delirium. To make the diagnosis of schizophrenia,
■■ Evidence from history, physical, or lab data to support a medication or a patient must have symptoms of the
substance-induced cause. disease for at least 6 months.
■■ Disturbance is not better accounted for by a psychotic disorder that is not
substance/medication-induced.
Schizophrenia
A 24-year-old male graduate student without prior medical or psy-

chiatric history is reported by his mother to have been very anxious
over the past 9 months, with increasing concern that people are watch-
ing him. He now claims to “hear voices” telling him what must be done
to “fix the country.” Important workup? Thyroid-stimulating hormone
(TSH), rapid plasma reagin (RPR), brain imaging. Likely diagnosis?
Schizophrenia. Next step? Antipsychotics.
Schizophrenia is a psychiatric disorder characterized by a constellation of

abnormalities in thinking, emotion, and behavior. There is no single symp-
tom that is pathognomonic, and there is a heterogeneous clinical presenta-
tion. Schizophrenia is typically chronic, with significant psychosocial and
medical consequences to the patient.
P O S I T I V E, N E GAT I V E, A N D C O G N I T I V E S Y M P T O M S
In general, the symptoms of schizophrenia are broken up into three

categories:
KEY FACT
■■ Positive symptoms: Hallucinations, delusions, bizarre behavior, disorganized
Think of positive symptoms as things speech. These tend to respond more robustly to antipsychotic medications.
that are ADDED onto normal behavior. ■■ Negative symptoms: Flat or blunted affect, anhedonia, apathy, alogia, and
Think of negative symptoms as things lack of interest in socialization. These symptoms are comparatively more
that are SUBTRACTED or missing from often treatment resistant and contribute significantly to the social isolation
normal behavior. of schizophrenic patients.
■■ Cognitive symptoms: Impairments in attention, executive function,
and working memory. These symptoms may → poor work and school
performance.
WARDS TIP
THR E E P HA S E S
Stereotyped movement, bizarre
posturing, and muscle rigidity
Symptoms of schizophrenia often present in three phases:
are examples of catatonia seen in
schizophrenic patients. 1. Prodromal: Decline in functioning that precedes the first psychotic episode.
The patient may become socially withdrawn and irritable. He or she may
have physical complaints, declining school/work performance, and/or new-
found interest in religion or the occult.
2. Psychotic: Perceptual disturbances, delusions, and disordered thought
process/content.
3. Residual: Occurs following an episode of active psychosis. It is marked by
mild hallucinations or delusions, social withdrawal, and negative symptoms.
KEY FACT
D I AG N O S I S O F S CH I Z O P HR E N I A
Clozapine is typically considered
for treating schizophrenia when a DSM-5 Criteria
patient fails both typical and other
■■ Two or more of the following must be present for at least 1 month:
atypical antipsychotics; this is due
1. Delusions
to the potential rare adverse event,
2. Hallucinations
agranulocytosis, which requires patients
3. Disorganized speech
be monitored (WBC and ANC counts)
4. Grossly disorganized or catatonic behavior
regularly.
5. Negative symptoms
Note: At least one must be 1, 2, or 3.
■■ Must cause significant social, occupational, or self-care functional
deterioration.
WARDS TIP ■■ Duration of illness for at least 6 months (including prodromal or residual
periods in which the above full criteria may not be met).
The 5 A’s of schizophrenia (negative ■■ Symptoms not due to effects of a substance or another medical condition.
symptoms):
1. Anhedonia
2. Affect (flat) Mr. Torres is a 21-year-old man who is brought to the ER by his
3. Alogia (poverty of speech) mother after he began talking about “aliens” who were trying to steal
4. Avolition (apathy) his soul. Mr. Torres reports that aliens left messages for him by arrang-
5. Attention (poor) ing sticks outside his home and sometimes send thoughts into his mind.
On exam, he is guarded and often stops talking while in the middle of WARDS TIP
expressing a thought. Mr. Torres appears anxious and frequently scans
the room for aliens, which he thinks may have followed him to the hos- Echolalia—repeats words or phrases
pital. He denies any plan to harm himself, but admits that the aliens EchoPRAxia—mimics behavior
sometimes want him to throw himself in front of a car, “as this will (PRActices behavior)
change the systems that belong under us.”
The patient’s mother reports that he began expressing these ideas a

few months ago, but that they have become more severe in the last few
weeks. She reports that during the past year, he has become isolated
from his peers, frequently talks to himself, and has stopped going to
community college. He has also spent most of his time reading science
fiction books and creating devices that will prevent aliens from hurt-
ing him. She reports that she is concerned because the patient’s father,
who left while the patient was a child, exhibited similar symptoms many
years ago and has spent most of his life in psychiatric hospitals.
What is Mr. Torres’s most likely diagnosis? What differential diagnoses

should be considered?
Mr. Torres’s most likely diagnosis is schizophrenia. He exhibits delu-

sional ideas that are bizarre and paranoid in nature. He also reports the
presence of frequent auditory hallucinations and disturbances in thought
process that include thought blocking. Although the patient’s mother
reports that his psychotic symptoms began “a few months ago,” the
patient has exhibited social and occupational dysfunction during the last
year. Mr. Torres quit school, became isolated, and has been responding
to internal stimuli since that time. In addition, his father appears to also
suffer from a psychotic disorder. In this case, it appears that the disorder
has been present for more than 6 months; however, if this is unclear, the
diagnosis of schizophreniform disorder should be made instead.
The differential diagnosis should also include schizoaffective disorder,

medication/substance-induced psychotic disorder, psychotic disorder
due to another medical condition, and mood disorder with psychotic
features.
What would be appropriate steps in the acute management of this

patient?
Treatment should include inpatient hospitalization in order to provide

a safe environment, with monitoring of suicidal ideation secondary to
his psychosis. Routine laboratory tests, including a urine or serum drug
screen, should be undertaken. The patient should begin treatment with
antipsychotic medication while closely being monitored for potential
side effects.
KEY FACT
P S YCH I ATR I C E X A M O F PAT I E N T S W I TH S CH I Z O P HR E N I A
Brief psychotic disorder lasts for < 1
The typical findings in schizophrenic patients include: month. Schizophreniform disorder
■■ Disheveled appearance can last between 1 and 6 months.
■■ Flat affect Schizophrenia lasts for > 6 months.
■■ Disorganized thought process
■■ Intact procedural memory and orientation

■■ Auditory hallucinations
■■ Paranoid delusions
■■ Ideas of reference
■■ Lack of insight into their disease
KEY FACT E P I D E M I O LO GY
■■ Schizophrenia affects approximately 0.3–0.7% of people over their lifetime.

People born in late winter and early
■■ Men and women are equally affected but have different presentations and
spring have a higher incidence of
outcomes:
schizophrenia for unknown reasons.
■■ Men tend to present in early to mid-20s
(One theory involves seasonal variation
■■ Women present in late 20s
in viral infections, particularly second
■■ Men tend to have more negative symptoms and poorer outcome com-
trimester exposure to influenza virus.)
pared to women.
■■ Schizophrenia rarely presents before age 15 or after age 55.
■■ There is a strong genetic predisposition:
■■ 50% concordance rate among monozygotic twins
■■ 40% risk of inheritance if both parents have schizophrenia
■■ 12% risk if one first-degree relative is affected
■■ Substance use is comorbid in many patients with schizophrenia. The most

commonly abused substance is nicotine (> 50%), followed by alcohol,
cannabis, and cocaine.
■■ Post-psychotic depression is the phenomenon of schizophrenic patients
developing a major depressive episode after resolution of their psychotic
symptoms.
KEY FACT D O W N W AR D D R I FT
Lower socioeconomic groups have higher rates of schizophrenia. This may be

Schizophrenia is found in lower
due to the downward drift hypothesis, which postulates that people suffering
socioeconomic groups likely due to
from schizophrenia are unable to function well in society and hence end up
“downward drift” (they have difficulty in
in lower socioeconomic groups. Many homeless people in urban areas suffer
holding good jobs, so they tend to drift
from schizophrenia.
downward socioeconomically).
PATH O P HY S I O LO GY O F S CH I Z O P HR E N I A : TH E D O PA M I N E HY P O TH E S I S
Though the exact cause of schizophrenia is not known, it appears to be partly

related to ↑ dopamine activity in certain neuronal tracts. Evidence to support
this hypothesis is that most antipsychotics successful in treating schizophrenia
are dopamine receptor antagonists. In addition, cocaine and amphetamines ↑
dopamine activity and can → schizophrenic-like symptoms.
KEY FACT Theorized Dopamine Pathways Affected in Schizophrenia

■■ Prefrontal cortical: Inadequate dopaminergic activity responsible for nega-
Akathisia is an unpleasant, subjective tive symptoms.
sense of restlessness and need to move, ■■ Mesolimbic: Excessive dopaminergic activity responsible for positive
often manifested by the inability to sit symptoms.
still.
Other Important Dopamine Pathways Affected by antipsychotics
■■ Tuberoinfundibular: Blocked by antipsychotics, causing hyperprolactinemia,
which may → gynecomastia, galactorrhea, sexual dysfunction, and men-
KEY FACT strual irregularities.
■■ Nigrostriatal: Blocked by antipsychotics, causing Parkinsonism/extrapyra-
The lifetime prevalence of midal side effects such as tremor, rigidity, slurred speech, akathisia, dysto-
schizophrenia is 0.3–0.7%. nia, and other abnormal movements.
O TH E R N E U R O TRA N S M I TT E R AB N O R M A L I T I E S I M P L I CAT E D
KEY FACT
I N S CH I Z O P HR E N I A
Schizophrenia has a large genetic
■■ Elevated serotonin: Some of the second-generation (atypical) antipsy-
component. If one identical twin has
chotics (e.g., risperidone and clozapine) antagonize serotonin and weakly
schizophrenia, the risk of the other
antagonize dopamine.
identical twin having schizophrenia
■■ Elevated norepinephrine: Long-term use of antipsychotics has been
is 50%. A biological child of a
shown to ↓ activity of noradrenergic neurons.
schizophrenic person has a higher
■■ ↓ gamma-aminobutyric acid (GABA): There is ↓ expression of the
chance of developing schizophrenia,
enzyme necessary to create GABA in the hippocampus of schizophrenic
even if adopted.
patients.
■■ ↓ levels of glutamate receptors: Schizophrenic patients have fewer
NMDA receptors; this corresponds to the psychotic symptoms observed
with NMDA antagonists like ketamine.
P R O G N O S T I C FACT O R S
Even with medication, 40–60% of patients remain significantly impaired KEY FACT
after their diagnosis, while only 20–30% function fairly well in society. About
20% of patients with schizophrenia attempt suicide and many more experi- Computed tomographic (CT) and
ence suicidal ideation. Several factors are associated with a better or worse magnetic resonance imaging (MRI)
prognosis: scans of patients with schizophrenia
may show enlargement of the
Associated with Better Prognosis ventricles and diffuse cortical atrophy
■■ Later onset and reduced brain volume.
■■ Good social support
■■ Positive symptoms
■■ Mood symptoms
■■ Acute onset
■■ Female gender
■■ Few relapses
■■ Good premorbid functioning
Associated with Worse Prognosis KEY FACT

■■ Early onset
■■ Poor social support

Schizophrenia often involves
■■ Negative symptoms
neologisms. A neologism is a newly
■■ Family history
coined word or expression that has
■■ Gradual onset
meaning only to the person who
■■ Male gender
uses it.
■■ Many relapses
■■ Poor premorbid functioning (social isolation, etc.)
■■ Comorbid substance use
TR E AT M E N T
A multimodal approach is the most effective, and therapy must be tailored to

the needs of the specific patient. Pharmacologic treatment consists primar-
WARDS TIP
ily of antipsychotic medications, otherwise known as neuroleptics. (For more
detail, see the Psychopharmacology chapter.)
First-generation antipsychotic
■■ First-generation (or typical) antipsychotic medications (e.g., chlorproma- medications are referred to as typical
zine, fluphenazine, haloperidol, perphenazine): or conventional antipsychotics (often
■■ These are primarily dopamine (mostly D2) antagonists. called neuroleptics). Second-generation
■■ Treat positive symptoms with minimal impact on negative symptoms. antipsychotic medications are referred
■■ Side effects include extrapyramidal symptoms, neuroleptic malignant to as atypical antipsychotics.
syndrome, and tardive dyskinesia (see below).
■■ Second-generation (or atypical) antipsychotic medications (e.g., aripip-

WARDS TIP razole, asenapine, clozapine, iloperidone, lurasidone, olanzapine, quetiap-
ine, risperidone, ziprasidone):
Schizophrenic patients who are treated ■■ These antagonize serotonin receptors (5-HT2) as well as dopamine
with second-generation (atypical) (D4>D2) receptors.
antipsychotic medications need a ■■ Research has shown no significant difference between first- and second-
careful medical evaluation for metabolic generation antipsychotics in efficacy. The selection requires the weighing
syndrome. This includes checking of benefits and risks in individual clinical cases.
weight, body mass index (BMI), fasting ■■ Lower incidence of extrapyramidal side effects, but ↑ risk for metabolic
blood glucose, lipid assessment, and syndrome.
blood pressure. ■■ Medications should be taken for at least 4 weeks before efficacy is
determined.
■■ Clozapine is reserved for patients who have failed multiple antipsy-
chotic trials due to its ↑ risk of agranulocytosis.

Behavioral therapy attempts to improve patients’ ability to function in soci-
ety. Patients are helped through a variety of methods to improve their social
skills, become self-sufficient, and minimize disruptive behaviors. Family
WARDS TIP therapy and group therapy are also useful adjuncts.
Patients who are treated with

Important Side Effects and Sequelae of Antipsychotic Medications
first-generation (typical) antipsychotic
medication need to be closely Side effects of antipsychotic medications include:
monitored for extrapyramidal 1. Extrapyramidal symptoms (especially with the use of high-potency first-
symptoms, such as acute dystonia generation antipsychotics):
and tardive dyskinesia. ■■ Dystonia (spasms) of face, neck, and tongue
■■ Parkinsonism (resting tremor, rigidity, bradykinesia)
■■ Akathisia (feeling of restlessness)
Treatment: Anticholinergics (benztropine, diphenhydramine), benzodiaz-

epines/beta-blockers (specifically for akathisia)
2. Anticholinergic symptoms (especially low-potency first-generation anti-
psychotics and atypical antipsychotics): Dry mouth, constipation, blurred
KEY FACT vision, hyperthermia.
Treatment: As per symptom (eye drops, stool softeners, etc.)
High-potency antipsychotics (such as 3. Metabolic syndrome (second-generation antipsychotics): A constellation
haloperidol and fluphenazine) have of conditions— ↑ blood pressure, ↑ blood sugar levels, excess body fat
a higher incidence of extrapyramidal around the waist, abnormal cholesterol levels—that occur together, ↑ the
side effects, while low-potency risk for developing cardiovascular disease, stroke, and type 2 diabetes.
antipsychotics (such as chlorpromazine) Treatment: Consider switching to a first-generation antipsychotic or a more
have primarily anticholinergic and “weight-neutral” second-generation antipsychotic such as aripiprazole or
antiadrenergic side effects. ziprasidone. Monitor lipids and blood glucose measurements. Refer the
patient to primary care for appropriate treatment of hyperlipidemia, diabe-
tes, etc. Encourage appropriate diet, exercise, and smoking cessation.
4. Tardive dyskinesia (more likely with first-generation antipsychotics):
Choreoathetoid movements, usually seen in the face, tongue, and head.
Treatment: Discontinue or reduce the medication and consider substituting an
atypical antispsychotic (if appropriate). Benzodiazepines, Botox, and vitamin
E may be used. The movements may persist despite withdrawal of the drug.
WARDS TIP Although less common, atypical antipsychotics can cause tardive dyskinesia.
5. Neuroleptic malignant syndrome (typically high-potency first-generation
Tardive dyskinesia occurs most often antipsychotics):
in older women after at least 6 months ■■ Change in mental status, autonomic instability (high fever, labile blood
of medication. A small percentage of pressure, tachycardia, tachypnea, diaphoresis), “lead pipe” rigidity, elevated
patients will experience spontaneous creatine phosphokinase (CPK) levels, leukocytosis, and metabolic acidosis.
remission, so discontinuation of the ■■ A medical emergency that requires prompt withdrawal of all antipsy-
agent should be considered if clinically chotic medications and immediate medical assessment and treatment.
appropriate. ■■ May be observed in any patient being treated with any antipsychotic
(including second generation) medications at any time, but is more

frequently associated with the initiation of treatment and at higher IV/

IM dosing of high-potency neuroleptics. KEY FACT
■■ Patients with a history of prior neuroleptic malignant syndrome are at
an ↑ risk of recurrent episodes when retrialed with antipsychotic agents. The cumulative risk of developing
6. Prolonged QTc interval and other electrocardiogram changes, hyperp- tardive dyskinesia from antipsychotics
rolactinemia (→ gynecomastia, galactorrhea, amenorrhea, diminished (particularly first generation) is 5% per
libido, and impotence), hematologic effects (agranulocytosis may occur year.
with clozapine, requiring frequent blood draws when this medication
is used), ophthalmologic conditions (thioridazine may cause irrevers-
ible retinal pigmentation at high doses; deposits in lens and cornea may
occur with chlorpromazine), dermatologic conditions (such as rashes and
photosensitivity).
Schizophreniform Disorder
KEY FACT
Diagnosis and DSM-5 Criteria
The diagnosis of schizophreniform disorder is made using the same DSM-5 If a schizophrenia presentation has
criteria as schizophrenia. The only difference between the two is that in not been present for 6 months, think
schizophreniform disorder the symptoms have lasted between 1 and 6 months, schizophreniform disorder.
whereas in schizophrenia the symptoms must be present for > 6 months.
Prognosis
One-third of patients recover completely; two-thirds progress to schizoaffec-
tive disorder or schizophrenia.
Treatment
Hospitalization (if necessary), 6-month course of antipsychotics, and support-
ive psychotherapy.
Schizoaffective Disorder
The diagnosis of schizoaffective disorder is made in patients who:
■■ Meet criteria for either a major depressive or manic episode during which
psychotic symptoms consistent with schizophrenia are also met.
■■ Delusions or hallucinations for 2 weeks in the absence of mood disorder
symptoms (this criterion is necessary to differentiate schizoaffective disor-

der from mood disorder with psychotic features).
■■ Mood symptoms present for a majority of the psychotic illness.
■■ Symptoms not due to the effects of a substance (drug or medication) or
another medical condition.
Prognosis
Worse with poor premorbid adjustment, slow onset, early onset, predominance
of psychotic symptoms, long course, and family history of schizophrenia.
Treatment
■■ Hospitalization (if necessary) and supportive psychotherapy.
■■ Medical therapy: Antipsychotics (second-generation medications may
target both psychotic and mood symptoms); mood stabilizers, antidepres-
sants, or electroconvulsive therapy (ECT) may be indicated for treatment
of mood symptoms.
KEY FACT
Brief Psychotic Disorder
Patients with borderline personality
disorder may have transient, stress-
related psychotic experiences. These Patient with psychotic symptoms as in schizophrenia; however, the symptoms
are considered part of their underlying last from 1 day to 1 month, and there must be eventual full return to pre-
personality disorder and not diagnosed morbid level of functioning. Symptoms must not be due to the effects of a
as a brief psychotic disorder. substance (drug or medication) or another medical condition. This is a rare
diagnosis, much less common than schizophrenia. It may be seen in reaction
to extreme stress such as bereavement, sexual assault, etc.
Prognosis
High rates of relapse, but almost all completely recover.
Treatment
Brief hospitalization (usually required for workup, safety, and stabilization),
supportive therapy, course of antipsychotics for psychosis, and/or benzodiaz-
epines for agitation.
Delusional Disorder
Delusional disorder occurs more often in middle-aged or older patients (after
age 40). Immigrants, the hearing impaired, and those with a family history of
schizophrenia are at increased risk.
To be diagnosed with delusional disorder, the following criteria must be met:
■■ One or more delusions for at least 1 month.
■■ Does not meet criteria for schizophrenia.
■■ Functioning in life not significantly impaired, and behavior not obviously
bizarre.
■■ While delusions may be present in both delusional disorder and schizo-
phrenia, there are important differences (see Table 3-1).
Types of Delusions
Patients are further categorized based on the types of delusions they experience:
■■ Erotomanic type: Delusion that another person is in love with the individual.
■■ Grandiose type: Delusions of having great talent.
■■ Somatic type: Physical delusions.
■■ Persecutory type: Delusions of being persecuted.
TA B L E 3 - 1. Schizophrenia versus Delusional Disorder
Schizophrenia Delusional Disorder
■■ Bizarre or nonbizarre delusions ■■ Usually nonbizarre delusions

■■ Daily functioning significantly impaired ■■ Daily functioning not significantly impaired
■■ Must have two or more of the following: ■■ Does not meet the criteria for schizophrenia
■■ Delusions as described in the left column
■■ Hallucinations
■■ Disorganized speech
■■ Disorganized behavior
■■ Negative symptoms
■■ Jealous type: Delusions of unfaithfulness.

■■ Mixed type: More than one of the above.
■■ Unspecified type: Not a specific type as described above.
Prognosis
■■ Better than schizophrenia with treatment:
■■ > 50%: Full recovery
■■ > 20%: ↓ symptoms
■■ < 20%: No change
Treatment
Difficult to treat, especially given the lack of insight and impairment.
Antipsychotic medications are recommended despite somewhat limited
evidence. Supportive therapy is often helpful, but group therapy should be
avoided given the patient’s suspiciousness.
Culture-Specific Psychoses
The following are examples of psychotic disorders seen within certain cultures:
Psychotic Manifestation Culture
Koro Intense anxiety that the penis will recede into the body, Southeast Asia
possibly leading to death. (e.g., Singapore)
Amok Sudden unprovoked outbursts of violence, often followed Malaysia

by suicide.
Brain fag Headache, fatigue, eye pain, cognitive difficulties, and other Africa
somatic disturbances in male students.
Comparing Time Courses and Prognoses

of Psychotic Disorders
KEY FACT
Time Course
■■ < 1 month—brief psychotic disorder SchizophreniFORM = the FORMation of
■■ 1–6 months—schizophreniform disorder a schizophrenic, but not quite there (i.e.,
■■ > 6 months—schizophrenia < 6 months).
Prognosis from Best to Worst

Mood disorder with psychotic features > schizoaffective disorder > schizo-
phreniform disorder > schizophrenia.
Q ui c k a nd E a s y D is t in g uis h in g Fe at u r es
■■ Schizophrenia: Lifelong psychotic disorder.

■■ Schizophreniform: Schizophrenia for > 1 and < 6 months.
■■ Schizoaffective: Schizophrenia + mood disorder.
■■ Schizotypal (personality disorder): Paranoid, odd or magical beliefs,
eccentric, lack of friends, social anxiety. Criteria for overt psychosis are
not met.
■■ Schizoid (personality disorder): Solitary activities, lack of enjoyment from
social interactions, no psychosis.
no t es
chapter 4
MOOD DISORDERS
Concepts in Mood Disorders 34 Specifiers for Depressive Disorders 39

Bereavement 40
Mood Disorders versus Mood Episodes 34
Bipolar I Disorder 40
Mood Episodes 34
Bipolar II Disorder 41
Major Depressive Episode (DSM-5 Criteria) 34
Specifiers for Bipolar Disorders 42
Manic Episode (DSM-5 Criteria) 34
Persistent Depressive Disorder (Dysthymia) 42
Hypomanic Episode 35
Cyclothymic Disorder 43
Differences between Manic and Hypomanic Episodes 35
Premenstrual Dysphoric Disorder 43
Mixed Features 35
Disruptive Mood Dysregulation Disorder (DMDD) 44
Mood Disorders 35 Other Disorders of Mood in DSM-5 45
Differential Diagnosis of Mood Disorders Due to Other Medical
Conditions 35
Substance/Medication-Induced Mood Disorders 36
Major Depressive Disorder (MDD) 36
33
34 chapter 4 MOOD DISORDERS
Concepts in Mood Disorders

A mood is a description of one’s internal emotional state. Both external and
WARDS TIP internal stimuli can trigger moods, which may be labeled as sad, happy, angry,
irritable, and so on. It is normal to have a wide range of moods and to have a
Major depressive episodes can be sense of control over one’s moods.
present in major depressive disorder,
persistent depressive disorder Patients with mood disorders (also called affective disorders) experience an
(dysthymia), or bipolar I/II disorder. abnormal range of moods and lose some level of control over them. Distress
may be caused by the severity of their moods and the resulting impairment in
social and occupational functioning.
Mood Disorders versus Mood Episodes

WARDS TIP
■■ Mood episodes are distinct periods of time in which some abnormal
When patients have delusions and mood is present. They include depression, mania, and hypomania.
hallucinations due to underlying ■■ Mood disorders are defined by their patterns of mood episodes. They
mood disorders, they are usually mood include major depressive disorder (MDD), bipolar I disorder, bipolar II
congruent. For example, depression disorder, persistent depressive disorder, and cyclothymic disorder. Some
causes psychotic themes of paranoia may have psychotic features (delusions or hallucinations).
and worthlessness, and mania causes
psychotic themes of grandiosity and
invincibility.
Mood Episodes
MA JOR DEPRESSIVE EPISODE (DSM-5 CRITERIA)
Must have at least five of the following symptoms (must include either num-
ber 1 or 2) for at least a 2-week period:
KEY FACT 1. Depressed mood most of the time
2. Anhedonia (loss of interest in pleasurable activities)
Symptoms of major depression— 3. Change in appetite or weight (↑ or ↓)
SIG E. CAPS (Prescribe Energy Capsules) 4. Feelings of worthlessness or excessive guilt
Sleep 5. Insomnia or hypersomnia
Interest 6. Diminished concentration
Guilt 7. Psychomotor agitation or retardation (i.e., restlessness or slowness)
Energy 8. Fatigue or loss of energy
Concentration 9. Recurrent thoughts of death or suicide
Appetite
Symptoms are not attributable to the effects of a substance (drug or medica-
Psychomotor activity
tion) or another medical condition, and they must cause clinically significant
Suicidal ideation
distress or social/occupational impairment.
MANIC EPISODE (DSM-5 CRITERIA)
A distinct period of abnormally and persistently elevated, expansive, or irrita-

WARDS TIP
ble mood, and abnormally and persistently increased goal-directed activity or
energy, lasting at least 1 week (or any duration if hospitalization is necessary),
A manic episode is a psychiatric
and including at least three of the following (four if mood is only irritable):
emergency; severely impaired
judgment can make a patient 1. Distractibility
dangerous to self and others. 2. Inflated self-esteem or grandiosity
3. ↑ in goal-directed activity (socially, at work, or sexually) or psychomotor
agitation
MOOD DISORDERS chapter 4 35
4. ↓ need for sleep

5. Flight of ideas or racing thoughts KEY FACT
6. More talkative than usual or pressured speech (rapid and uninterruptible)
7. Excessive involvement in pleasurable activities that have a high risk of Symptoms of mania—
negative consequences (e.g., shopping sprees, sexual indiscretions) DIG FAST
Distractibility
Symptoms are not attributable to the effects of a substance (drug or medica- Insomnia/Impulsive behavior
tion) or another medical condition, and they must cause clinically signifi- Grandiosity
cant distress or social/occupational impairment. Greater than 50% of manic Flight of ideas/Racing thoughts
patients have psychotic symptoms. Activity/Agitation
Speech (pressured)
HYPOMANIC EPISODE Thoughtlessness
A hypomanic episode is a distinct period of abnormally and persistently

elevated, expansive, or irritable mood, and abnormally and persistently
increased goal-directed activity or energy, lasting at least 4 consecutive days,
that includes at least three of the symptoms listed for the manic episode cri-
teria (four if mood is only irritable). There are significant differences between WARDS TIP
mania and hypomania (see below).
Irritability is often the predominant
mood state in mood disorders with
DIFFERENCES BETWEEN MANIC AND HYPOMANIC EPISODES mixed features. Patients with mixed
features have a poorer response to
Mania Hypomania lithium. Anticonvulsants such as
valproic acid may be more helpful.
Lasts at least 7 days Lasts at least 4 days
Causes severe impairment in social No marked impairment in social
or occupational functioning or occupational functioning
May necessitate hospitalization to Does not require hospitalization
prevent harm to self or others No psychotic features
May have psychotic features
M I X E D F E AT U R E S
Criteria are met for a manic or hypomanic episode and at least three symp-
toms of a major depressive episode are present for the majority of the time.
These criteria must be present nearly every day for at least 1 week.
Mood Disorders
Mood disorders often have chronic courses that are marked by relapses with
relatively normal functioning between episodes. Like most psychiatric diagno-
ses, mood episodes may be caused by another medical condition or drug (pre-
scribed or illicit); therefore, always investigate medical or substance-induced
causes (see below) before making a primary psychiatric diagnosis.
DIFFERENTIAL DIAGNOSIS OF MOOD DISORDERS DUE TO OTHER MEDIC AL

CONDITIONS
Medical Causes of a Depressive Medical Causes of a Manic
Episode Episode
Cerebrovascular disease (stroke, Metabolic (hyperthyroidism)

myocardial infarction) Neurological disorders
Endocrinopathies (diabetes mellitus, (temporal lobe seizures,
Cushing syndrome, Addison disease, multiple sclerosis)
hypoglycemia, Neoplasms
hyper/hypothyroidism, HIV infection
hyper/hypocalcemia)
Parkinson’s disease
Viral illnesses (e.g., mononucleosis)
Carcinoid syndrome
Cancer (especially lymphoma and
pancreatic carcinoma)
Collagen vascular disease (e.g.,
systemic lupus erythematosus)
S U B S TA N C E / M E D I C AT I O N - I N D U C E D M O O D D I S O R D E R S
Substance/Medication-Induced Subst ance/Medication-Induced

Depressive Disorder Bipolar Disorder
EtOH Antidepressants
Antihypertensives Sympathomimetics
Barbiturates Dopamine
KEY FACT Corticosteroids Corticosteroids
Levodopa Levodopa
Stroke patients are at a significant risk Sedative-hypnotics Bronchodilators
for developing depression, and this Anticonvulsants Cocaine
is associated with a poorer outcome Antipsychotics Amphetamines
overall. Diuretics
Sulfonamides
Withdrawal from
stimulants (e.g., cocaine,
amphetamines)
KEY FACT M ajor D epressive D isorder ( M D D )
Major depressive disorder is the most MDD is marked by episodes of depressed mood associated with loss of inter-
common disorder among those who est in daily activities. Patients may not acknowledge their depressed mood or
complete suicide. may express vague, somatic complaints (fatigue, headache, abdominal pain,
muscle tension, etc.).

■■ At least one major depressive episode (see above).
■■ No history of manic or hypomanic episode.
KEY FACT
Epidemiology
Most adults with depression do not
see a mental health professional, but
■■ Lifetime prevalence: 12% worldwide.
they often present to a primary care
■■ Onset at any age, but the age of onset peaks in the 20s.
physician for other reasons.
■■ 1.5–2 times as prevalent in women than men during reproductive years.
■■ No ethnic or socioeconomic differences.
■■ Lifetime prevalence in the elderly: <10%.
■■ Depression can ↑ mortality for patients with other comorbidities such as
diabetes, stroke, and cardiovascular disease.
KEY FACT
Sleep Problems Associated with MDD
Anhedonia is the inability to experience
■■ Multiple awakenings.
pleasure, which is a common finding in
■■ Initial and terminal insomnia (hard to fall asleep and early morning
depression.
awakenings).
■■ Hypersomnia (excessive sleepiness) is less common.
■■ Rapid eye movement (REM) sleep shifted earlier in the night and for a
greater duration, with reduced stages 3 and 4 (slow wave) sleep.
Etiology
WARDS TIP
The precise cause of depression is unknown, but MDD is believed to be a
heterogeneous disease, with biological, genetic, environmental, and psychoso- The two most common types of sleep
cial factors contributing. disturbances associated with MDD
■■ MDD is likely caused by neurotransmitter abnormalities in the brain. are difficulty falling asleep and early
Evidence for this is the following: antidepressants exert their therapeutic effect morning awakenings.
by increasing catecholamines; ↓ cerebrospinal fluid (CSF) levels of 5-hydroxy-
indolacetic acid (5-HIAA), the main metabolite of serotonin, have been found
in depressed patients with impulsive and suicidal behavior.
■■ Increased sensitivity of beta-adrenergic receptors in the brain has also been KEY FACT
postulated in the pathogenesis of MDD.
■■ High cortisol: Hyperactivity of hypothalamic-pituitary-adrenal axis, as shown The Hamilton Depression Rating Scale
by failure to suppress cortisol levels in the dexamethasone suppression test. measures the severity of depression
■■ Abnormal thyroid axis: Thyroid disorders are associated with depressive and is used in research to assess the
symptoms. effectiveness of therapies. PHQ-9 is a
■■ Gamma-aminobutyric acid (GABA), glutamate, and endogenous opiates depression screening form often used
may additionally have a role. in the primary care setting.
■■ Psychosocial/life events: Multiple adverse childhood experiences are a
risk factor for later developing MDD.
■■ Genetics: First-degree relatives are two to four times more likely to have
MDD. Concordance rate for monozygotic twins is <40%, and 10–20% for
dizygotic twins. KEY FACT
Course and Prognosis Loss of a parent before age 11 is

associated with the later development
■■ Untreated, depressive episodes are self-limiting but last from 6 to 12
of major depression.
months. Generally, episodes occur more frequently as the disorder pro-
gresses. The risk of a subsequent major depressive episode is 50–60%
within the first 2 years after the first episode. 2–12% of patients with MDD
eventually commit suicide. KEY FACT
■■ Approximately 60% of patients show a significant response to antidepres-
sants. Combined treatment with both an antidepressant and psychother- Depression is common in patients with
apy produce a significantly ↑ response for MDD. pancreatic cancer.
Treatment
Hospitalization
KEY FACT
■■ Indicated if patient is at risk for suicide, homicide, or is unable to care for
him/herself.
Only half of patients with MDD receive
Pharmacotherapy treatment.
■■ Antidepressant medications:
■■ Selective serotonin reuptake inhibitors (SSRIs): Safer and better toler-
ated than other classes of antidepressants; side effects are mild but
include headache, gastrointestinal disturbance, sexual dysfunction, and KEY FACT
rebound anxiety. Medications that also have activation of other neu-
rotransmitters include serotonin-norepinephrine reuptake inhibitors All antidepressant medications are
venlafaxine (Effexor) and duloxetine (Cymbalta), the α2-adrenergic equally effective but differ in side-effect
receptor antagonist mirtazapine (Remeron), and the dopamine-norepi- profiles. Medications usually take 4–6
nephrine reuptake inhibitor bupropion (Wellbutrin). weeks to fully work.
■■ Tricyclic antidepressants (TCAs): Most lethal in overdose due to cardiac
arrhythmias; side effects include sedation, weight gain, orthostatic hypoten-

sion, and anticholinergic effects. Can aggravate prolonged QTc syndrome.
■■ Monoamine oxidase inhibitors (MAOIs): Older medications occa-
sionally used for refractory depression; risk of hypertensive crisis when

used with sympathomimetics or ingestion of tyramine-rich foods, such
as wine, beer, aged cheeses, liver, and smoked meats (tyramine is an
intermediate in the conversion of tyrosine to norepinephrine); risk of
serotonin syndrome when used in combination with SSRIs. Most com-

WARDS TIP mon side effect is orthostatic hypotension.
Serotonin syndrome is marked by ■■ Adjunct medications:
autonomic instability, hyperthermia, ■■ Atypical (second-generation) antipsychotics along with antidepressants
hyperreflexia (including myoclonus), are first-line treatment in patients with MDD with psychotic features.
and seizures. Coma or death may result. In addition, they may also be prescribed in patients with treatment
resistant/refractory MDD without psychotic features.
■■ Triiodothyronine (T ), levothyroxine (T ), and lithium have demon-
3 4
strated some benefit when augmenting antidepressants in treatment
refractory MDD.
■■ While stimulants (such as methylphenidate) may be used in certain
WARDS TIP
patients (e.g., terminally ill), the efficacy is limited and trials are small.
Adjunctive treatment is usually Psychotherapy
performed after multiple first-line ■■ Cognitive-behavioral therapy (CBT), interpersonal psychotherapy, sup-
treatment failures. portive therapy, psychodynamic psychotherapy, problem-solving therapy,
and family/couples therapy have all demonstrated some benefit in treating
MDD (primarily CBT or interpersonal psychotherapy).
■■ May be used alone or in conjunction with pharmacotherapy.
Electroconvulsive Therapy (ECT)

■■ Indicated if patient is unresponsive to pharmacotherapy, if patient can-
KEY FACT not tolerate pharmacotherapy (pregnancy, etc.), or if rapid reduction
of symptoms is desired (e.g., immediate suicide risk, refusal to eat/drink,
Postpartum period conveys an elevated catatonia).
risk of depression in women. ■■ ECT is extremely safe (primary risk is from anesthesia) and may be used
alone or in combination with pharmacotherapy.

■■ ECT is often performed by premedication with atropine, followed by gen-
eral anesthesia (usually with methohexital) and administration of a muscle

relaxant (typically succinylcholine). A generalized seizure is then induced
WARDS TIP by passing a current of electricity across the brain (generally bilateral, less
commonly unilateral); the seizure should last between 30 and 60 seconds,
MAOIs were considered particularly
and no longer than 90 seconds.
■■ 6–12 (average of 7) treatments are administered over a 2- to 3-week period,
useful in the treatment of “atypical”
depression; however, SSRIs remain
but significant improvement is sometimes noted after the first treatment.
■■ Retrograde and anterograde amnesia are common side effects, which usu-
first-line treatment for major depressive
episodes with atypical features.
ally resolve within 6 months.
■■ Other common but transient side effects: Headache, nausea, muscle
soreness.
Ms. Cruz is a 28-year-old sales clerk who arrives at your outpatient

clinic complaining of sadness after her boyfriend of 6 months ended
their relationship 1 month ago. She describes a history of failed roman-
tic relationships, and says, “I don’t do well with breakups.” Ms. Cruz
reports that, although she has no prior psychiatric treatment, she was
urged by her employer to seek therapy. Ms. Cruz has arrived late to work
on several occasions because of oversleeping. She also has difficulty in
getting out of bed stating, “It’s difficult to walk; it’s like my legs weigh a
ton.” She feels fatigued during the day despite spending over 12 hours in
bed, and is concerned that she might be suffering from a serious medical
condition. She denies any significant changes in appetite or weight since
these symptoms began.
Ms. Cruz reports that, although she has not missed workdays, she has
difficulty concentrating and has become tearful in front of clients while
worrying about not finding a significant other. She feels tremendous

guilt over “not being good enough to get married,” and says that her
close friends are concerned because she has been spending her week-
ends in bed and not answering their calls. Although during your evalu-
ation Ms. Cruz appeared tearful, she brightened up when talking about
her newborn nephew and her plans of visiting a college friend next sum-
mer. Ms. Cruz denied suicidal ideation.
What is Ms. Cruz’s diagnosis?

Ms. Cruz’s diagnosis is major depressive disorder with atypical features.
She complains of sadness, fatigue, poor concentration, hypersomnia,
feelings of guilt, anhedonia, and impairment in her social and occupa-
tional functioning. The atypical features specifier is given in this case
as she exhibited mood reactivity (mood brightens in response to posi-
tive events) when talking about her nephew and visiting her friend, and
complained of a heavy feeling in her legs (leaden paralysis) and hyper-
somnia. It is also important to explore Ms. Cruz’s history of “not doing
well with breakups,” as this could be indicative of a long pattern of
interpersonal rejection sensitivity. Although it is common for patients
who suffer from atypical depression to report an ↑ in appetite, Ms. Cruz
exhibits enough symptoms to fulfill atypical features criteria. Adjustment
disorder should also be considered in the differential diagnosis.
What would be your pharmacological recommendation?

Ms. Cruz should be treated with an antidepressant medication. While
MAOIs such as phenelzine had traditionally been superior to TCAs in
the treatment of MDD with atypical features, SSRIs would be the first-
line treatment. The combination of pharmacotherapy and psychother-
apy has been shown to be more effective for treating mild-to-moderate
MDD than either treatment alone.
S pecifiers for D epressive D isorders
■■ Melancholic features: Present in approximately 25–30% of patients with

MDE and more likely in severely ill inpatients, including those with psy-
chotic features. Characterized by anhedonia, early morning awakenings,
depression worse in the morning, psychomotor disturbance, excessive
guilt, and anorexia. For example, you may diagnose major depressive disor-
der with melancholic features.
■■ Atypical features: Characterized by hypersomnia, hyperphagia, reactive
mood, leaden paralysis, and hypersensitivity to interpersonal rejection.
■■ Mixed features: Manic/hypomanic symptoms present during the majority
of days during MDE: elevated mood, grandiosity, talkativeness/pressured
speech, flight of ideas/racing thoughts, increased energy/goal-directed
activity, excessive involvement in dangerous activities, and decreased need
for sleep.
■■ Catatonia: Features include catalepsy (immobility), purposeless motor
activity, extreme negativism or mutism, bizarre postures, and echolalia.
Especially responsive to ECT. (May also be applied to bipolar disorder.)
■■ Psychotic features: Characterized by the presence of delusions and/or hal-
lucinations. Present in 24–53% of older, hospitalized patients with MDD.
Another random document with
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visit of their Royal Highnesses the Duke and Duchess of York
to the colonies of Australasia in the spring of next year. His
Royal Highness the Duke of York will be commissioned by her
Majesty to open the first Session of the Parliament of the
Australian Commonwealth in her name. Although the Queen
naturally shrinks from parting with her grandson for so long a
period, her Majesty fully recognizes the greatness of the
occasion which will bring her colonies of Australia into
federal union, and desires to give this special proof of her
interest in all that concerns the welfare of her Australian
subjects. Her Majesty at the same time wishes to signify her
sense of the loyalty and devotion which have prompted the
spontaneous aid so liberally offered by all the colonies in
the South African war, and of the splendid gallantry of her
colonial troops. Her Majesty's assent to this visit is, of
course, given on the assumption that at the time fixed for the
Duke of York's departure the circumstances are as generally
favourable as at present and that no national interests call
for his Royal Highness's presence in this country."
To manifest still further the interest taken by the British

government in the event, it was made known in October that
"when the Duke of York opens the new Commonwealth Parliament,
the guard of honour, it is directed, shall be so made up as to
be representative of every arm of the British Army, including
the Volunteers. To the Victoria and St. George's Rifles has
fallen the honour of being selected to represent the entire
Volunteer force of the country. A detachment of the regiment,
between 50 and 60 strong, will accordingly leave for Australia
in about a month and will be absent three or four months."
The honor of the appointment to be the first Governor-General

of the new Commonwealth fell to a Scottish nobleman, John
Adrian Louis Hope, seventh Earl of Hopetoun, who had been
Governor of Victoria from 1889 to 1895, and had held high
offices at home, including that of Lord Chamberlain in the
household of the Queen. Lord Hopetoun landed at Sydney on the
15th of December and received a great welcome. On the 30th,
his Cabinet was formed, and announced, as follows:
Mr. Barton, Prime Minister and Minister for External Affairs;

Mr. Deakin, Attorney-General;
Sir William Lyne, Minister for Home Affairs;
Sir George Turner, Treasurer;
Mr. Kingston, Minister of Trade and Commerce;
Mr. Dickson, Minister of Defence;
Sir John Forrest, Postmaster-General.
AUSTRALIA: A. D. 1901 (January).

Inauguration of the Federal Government.
The government of the Commonwealth was inaugurated with

splendid ceremonies on the first day of the New Year and the
New Century, when the Governor-General and the members of the
Federal Cabinet were sworn and assumed office. Two messages
from the British Secretary of State for the Colonies were
read, as follows:
{34}
"The Queen commands me to express through you to the people of

Australia her Majesty's heartfelt interest in the inauguration
of the Commonwealth, and her earnest wish that, under divine
Providence, it may ensure the increased prosperity and
well-being of her loyal and beloved subjects in Australia."
"Her Majesty's Government send cordial greetings to the

Commonwealth of Australia. They welcome her to her place among
the nations united under her Majesty's sovereignty, and
confidently anticipate for the new Federation a future of
ever-increasing prosperity and influence. They recognize in
the long-desired consummation of the hopes of patriotic
Australians a further step in the direction of the permanent
unity of the British Empire, and they are satisfied that the
wider powers and responsibilities henceforth secured to
Australia will give fresh opportunity for the display of that
generous loyalty and devotion to the Throne and Empire which
has always characterized the action in the past of its several
States."
AUSTRALIA: A. D. 1901 (May).

Opening of the first Parliament of the Commonwealth
by the heir to the British crown.
The programme of the Federal Government.
The Duke of Cornwall and York, heir to the British crown (but
not yet created Prince of Wales), sailed, with his wife, from
England in March, to be present at the opening of the first
Parliament of the federated Commonwealth of Australia, which
is arranged to take place early in May. He makes the voyage in
royal state, on a steamer specially fitted and converted for
the occasion into a royal yacht, with an escort of two
cruisers.
Preliminary to the election and meeting of Parliament, the new

federal government has much organizing work to do, and much
preparation of measures for Parliament to discuss. The
Premier, Mr. Barton, in a speech made on the 17th of January,
announced that the Customs were taken over from the several
States on January 1, and the defences and post-offices would
be transferred as soon as possible. " Probably the railways
would be acquired by the Commonwealth at an early date.
Whether the debts of the several States would be taken over
before the railways was a matter which had to be decided, and
was now engaging the attention of the Treasurer. The Ministry
would not consider the appointment of a Chief Justice of the
High Court until Parliament had established that tribunal." In
the same speech, the main features of the programme and policy
of the federal government were indicated. "The Commonwealth,"
said the Premier, "would have the exclusive power of imposing
Customs and excise duties, and it would, therefore, be
necessary to preserve the States' power of direct taxation.
There must be no direct taxation by the Commonwealth except
under very great pressure. Free trade under the Constitution
was practically impossible; there must be a very large Customs
revenue. … The policy of the Government would be protective, not
prohibitive, because it must be revenue-producing. No one
colony could lay claim to the adoption of its tariff, whether
high or low. The first tariff of Australia ought to be
considerate of existing industries. The policy of the
Government could be summed up in a dozen words. It would give
Australia a tariff that would be Australian. Regarding a
preferential duty on British goods, he would be glad to
reciprocate where possible, but the question would have to
receive very serious consideration before final action could
be taken. Among the legislation to be introduced at an early
date, Mr. Barton continued, were a Conciliation and
Arbitration Bill in labour disputes, and a Bill for a
transcontinental railway, which would be of great value from
the defence point of view. He was in favour of womanhood
suffrage. Legislation to exclude Asiatics would be taken in
hand as a matter of course."
----------AUSTRALIA: End--------
----------AUSTRIA-HUNGARY: Start--------
AUSTRIA-HUNGARY:
Financial relations of the two countries
forming the dual Empire.
"The financial relations of Austria and Hungary fall under

three main heads. Firstly, the Quota, or proportionate
contribution to joint expenditure. The Quota is an integral
portion of the compact of 1867 [see—in volume 1—AUSTRIA: A. D.
1866-1867], but is revised every ten years. Failing an
agreement on the proportion to be paid by each half of the
monarchy, the Quota is fixed from year to year by the Emperor
till an agreement is arrived at. Secondly, the so-called
commercial 'Ausgleich' treaty, which provides for a customs
union, postal and telegraphic union, commercial equality of
citizens of one state in the other, identical excise duties,
&c. Thirdly, the Bank Union, by which Austria and Hungary have
a common Austro-Hungarian bank, and common paper money. The
Ausgleich and Bank Union are not essential parts of the 1867
compact; they are really only treaties renewable every ten
years, and if no agreement is come to, they simply lapse, and
each state makes its own arrangements, which seems very likely
to be the fate of the Ausgleich unless the present crisis can
be got over. The proceeds of the joint customs are applied
directly to common expenses, and only the difference is made
up by Quota. But if the Ausgleich falls through, the whole of
the joint expenditure will have to be settled by quota
payments. The joint expenditure goes almost wholly to the
up-keep of the army, navy, and consular and diplomatic
services. It amounts on an average to about 150 million
florins or 12½ million £, falling as low as 124½ million
florins in 1885 and rising to nearly 167 million in 1888. Of
this total the customs revenues have, in the last few years,
accounted for nearly a third, usually about 31 per cent. The
Quota was fixed in 1867 at 70 per cent. for Austria and 30 per
cent. for Hungary, based on a very rough calculation from the
yield of common taxation in the years 1860-1865, the last few
years preceding the restoration of Hungarian independence. On
the incorporation of the so-called Military Frontier in
Hungary, the Hungarian proportion was increased to 31.4.
Hitherto the Hungarians have resisted any attempt to increase
their quota. This 'non possumus' attitude has provoked great
resentment in Austria, especially when it is compared with the
self-complacent tone with which the Magyars dwell on the enormous
progress made by Hungary since 1867. That progress is
indubitable. Hungary has not only developed as an agricultural
state, but is in a very fair way of becoming an industrial and
manufacturing state as well. …
{35}
"On all these grounds the Austrians declare that they can no
longer go on paying the old Quota of 68.6 per cent. The
Hungarians admit the great progress made by Hungary, but with
some qualifications. In spite of the growth of Budapest,
Fiume, and a few other towns, Hungary is still, on the whole,
very backward when compared with Austria. The total volume of
her manufactures is very small, in spite of the rapid increase
of recent years. Hungary is still, to all intents and
purposes, an agricultural country, and as such, has suffered
largely from the fall in prices."
L. S. Amery,
Austro-Hungarian Financial Relations
(Economic Journal, September, 1898).
AUSTRIA-HUNGARY: A. D. 1894-1895.
The Hungarian Ecclesiastical Laws.
Conflict with the Church.
Resignation of Count Kalnoky.
In the last month of 1894 royal assent was given to three

bills, known as the Ecclesiastical Laws, which marked an
extraordinary departure from the old subserviency of the State
to the Church. The first was a civil marriage law, which made
civil marriage compulsory, leaving religious ceremonies
optional with the parties, and which modified the law of
divorce; the second annulled a former law by which the sons of
mixed marriages were required to follow the father's religion,
and the daughters to follow that of the mother; the third
established an uniform State registration of births, deaths
and marriages, in place of a former registration of different
creeds, and legalized marriages between Christians and Jews
without change of faith. These very radical measures, after
passing the lower house of the Hungarian legislature, were
carried with great difficulty through the aristocratic and
clerical upper house, and only by a strong pressure of
influence from the emperor-king himself. They were exceedingly
obnoxious to the Church, and the Papal Nuncio became active in
a hostility which the Hungarian premier, Baron Banffy, deemed
offensive to the State. He called upon the Imperial Minister
of Foreign Affairs, Count Kalnoky, to address a complaint on
the subject to the Vatican. This led to disagreements between
the two ministers which the Emperor strove without success to
reconcile, and Count Kalnoky, in the end, was forced to retire
from office. The Pope was requested to recall the offending
Nuncio, and declined to do so.
AUSTRIA-HUNGARY: A. D. 1895-1896.
Race-jealousies and conflicts.
The position of Bohemia in the part of the dual Empire
called Austria.
Anti-Semitic agitation in Vienna.
Austrian Ministry of Count Badeni.
Enlarged parliamentary franchise.
In the constitutional reconstruction of the Empire after the

war of 1866, almost everything was conceded to the Magyars of
Hungary, who acquired independence in matters of internal
administration, and ascendancy over the other races subject to
the Hungarian crown. "On the other hand, absolute equality was
established between the different countries that are not
connected with Hungary. No greater privileges were granted to
an ancient historical kingdom such as Bohemia than were given,
for instance, to the small Alpine district situated between
the Tyrol and the Boden See (Lake of Constance) known as
Vorarlberg. … The representatives of these countries were to
meet at Vienna, and a ministry for 'Cisleithania' was
appointed. That these measures were injudicious is now the
opinion of almost all Austrians. Beust [the Saxon statesman
who was called in to conduct the political reconstruction of
1867—see, in volume 1, AUSTRIA: A. D. 1866-1867; and
1866-1887], created a new agglomeration of smaller and larger
countries, entirely different as regards race, history, and
culture. It is characteristic of the artificiality of Count
Beust's new creation that up to the present day no real and
generally accepted name for it has been found. The usual
designation of Cisleithania is an obvious absurdity. A glance
at the map will suffice to show how senseless such a name is
when applied, for instance, to Dalmatia, one of the countries
ruled from Vienna. The word 'Austria' also can correctly be
applied only either to all the countries ruled by the house of
Habsburg-Lorraine or to the archduchies of Upper and Lower
Austria, which are the cradle of the dynasty. The official
designation of the non-Hungarian parts of the empire is 'the
kingdoms and lands represented in the parliament' (of
Vienna)—'Die im Reichsrathe vertretenen Königreiche und
Länder.'
"Though the Germans willingly took part in the deliberations

of the Parliament of 'Cisleithania,' the Slavs of Bohemia and
Poland were at first violently opposed to the new institution.
They might perhaps have willingly consented to take part in a
Vienna parliament that would have consisted of representatives
of the whole empire. But when the ancient historical rights of
Hungary were fully recognized, countries such as Bohemia and
Poland … naturally felt offended. Count Beust dealt
differently with these two divisions of the empire. The partly
true, partly imaginary, grievances of the Poles were more
recent and better known thirty years ago than they are now.
Beust was impressed by them and considered it advisable to
make large concessions to the Poles of Galicia with regard to
autonomy, local government, and the use of the national
language. The Poles, who did not fail to contrast their fate
with that of their countrymen who were under Russian or
Prussian rule, gratefully accepted these concessions, and
attended the meetings of the representative assembly at
Vienna. Other motives also contributed to this decision of the
Galician Poles. Galicia is a very poor country, and the Germans
who then ruled at Vienna, naturally welcoming the
representatives of a large Slav country in their Parliament,
proved most generous in their votes in favour of the Galician
railways. Matters stood differently in Bohemia, and the
attitude of Count Beust and the new 'Cisleithanian' ministers
was also here quite different. They seem to have thought that
they could break the resistance of the Bohemians by military
force, and with the aid of the German minority of the
population. A long struggle ensued. … Bohemia is … the
'cockpit' of Austrian political warfare, and almost every
political crisis has been closely connected with events that
occurred in Bohemia. The Bohemian representatives in 1867
refused to take part in the deliberations of the Vienna
Parliament, the existence of which they considered contrary to
the ancient constitution of their country.
{36}
In 1879 they finally decided to take part in the deliberations
of the Vienna assembly. … The Bohemians, indeed, entered the
Vienna Parliament under protest, and declared that their
appearance there was by no means to be considered as a
resignation of the special rights that Bohemia had formerly
possessed. The Bohemian deputies, however, continued
henceforth to take part in the deliberations of the
Cisleithanian Parliament and loyally supported those of the
many Austrian ministers who were not entirely deaf to their
demands. Some of these demands, such as that of the foundation
of a national university at Prague, were indeed granted by the
Vienna ministers. Though a German university continued to exist
at Prague, this concession was vehemently opposed by the
Germans, as indeed every concession to appease the Bohemian
people was."
Francis Count Lutzow,

Austria at the End of the Century
(Nineteenth Century Review, December, 1899).
During recent years, government in the dual empire has been

made increasingly difficult, especially on the Austrian side,
by the jealousy, which grows constantly more bitter, between
the German and Slavic elements of the mixed population, and by
the rising heat of the Anti-Semitic agitation. The latter was
brought to a serious crisis in Vienna during 1895 by the
election of Dr. Lueger, a violent leader of Anti-Semitism, to
the office of First Vice-Burgomaster, which caused the
resignation of the Burgomaster, and led to such disorders in
the municipal council that the government was forced to
intervene. The council was dissolved and an imperial
commissioner appointed to conduct the city administration
provisionally; but similar disorders, still more serious,
recurred in October, when elections were held and the
Anti-Semites won a majority in the council. Dr. Lueger was
then elected Burgomaster. The government, supported by a
majority in the Austrian Reichsrath, refused to confirm the
election. A second time Dr. Lueger was elected; whereupon the
municipal council was again dissolved and the municipal
administration transferred to an imperial commissioner. This
measure was followed by scenes of scandalous turbulence in the
Reichsrath and riotous demonstrations in the streets, which
latter were vigorously suppressed by the police. Some
considerable part of the temper in these demonstrations was
directed against the Austrian premier, Count Badeni, and still
more against the Polish race, to which he belonged. Count
Badeni, who had been Governor of Galicia, had just been called
to the head of affairs, and gave promise of an administration
that would be strong; but several other members of his cabinet
were Poles, and that fact was a cause of offense. He gave an
early assurance that the demand for an enlargement of the
parliamentary franchise should be satisfactorily met, and that
other liberal measures should be promptly taken in hand. These
promises, with the show of firmness in the conduct of the
government, produced a wide feeling in its favor. The promise
of an enlargement of the parliamentary franchise in Austria
was redeemed the following February (1896), by the
introduction and speedy passage of a parliamentary reform
bill, which embodied an important revision of the Austrian
constitution. Seventy-two new members were added to the 353
which formerly constituted the lower or Abgeordneten House of
the Austrian Reichsrath. The original body of 353 remained as
it had been, made up in four sections, elected by four classes
in the community, namely: owners of large estates, electing 85
members; doctors of the universities and town taxpayers who
pay five florins of direct taxation yearly, these together
electing 115; chambers of commerce and industry, electing 22;
country taxpayers who pay five florins of direct taxation
yearly, electing 131. The number of voters in these four
privileged classes were said to number 1,732,000 when the
Reform Bill passed. The new voters added by the bill were
estimated to number about 3,600,000. But the latter would
elect only the 72 new members added to the House, while the
former continued to be exclusively represented by the 353
members of its former constitution. In other words, though the
suffrage was now extended to all male adults, it was not with
equality of value to all. For about one-third of the political
community, the franchise was given five times the weight and
force that it possessed for the remaining two-thirds.
Nevertheless, the bill seems to have been accepted and passed
with no great opposition. In Vienna, the Anti-Semitic
agitation was kept up with violence, Dr. Lueger being elected
four times to the chief-burgomastership of the city, in
defiance of the imperial refusal to sanction his election.
Finally the conflict was ended by a compromise. Lueger
resigned and was permitted to take the office of Vice
Burgomaster, while one of his followers was chosen to the
Chief Burgomaster's seat.
AUSTRIA-HUNGARY: A. D. 1896.
Celebration of the Millennium of the Kingdom of Hungary.
The millennial anniversary of the Kingdom of Hungary was

celebrated by the holding of a great national exposition and
festival at Buda-Pesth, from the 2d of May until the end of
October, 1896. Preparations were begun as early as 1893, and
were carried forward with great national enthusiasm and
liberality, the government contributing nearly two millions of
dollars to the expense of the undertaking. The spirit of the
movement was expressed at the beginning by the Minister of
Commerce, Bela Lukács, by whose department it was specially
promoted. "The government," he said, "will take care that the
national work be exhibited in a worthy frame, so as to further
the interests of the exhibitors. May everyone of you, its
subjects, therefore show what he is able to attain by his
diligence, his taste, and his inventive faculty. Let us all,
in fact, compete—we who are working, some with our brains,
others with our hands, and others with our machines—like one
man for the father-land. Thus the living generation will be
able to see what its fore-fathers have made in the midst of
hard circumstances, and to realize what tasks are awaiting us
and the new generations in the path which has been smoothed by
the sweat, labor, and pain of our ancestors. This will be a
rare family festival, the equal of which has not been granted
to many nations. Let the people gather, then, round our august
ruler, who has guided our country with fatherly care and
wisdom in the benevolent ways of peace to the heights which
mark the progress of to-day, and who—a faithful keeper of the
glorious past of a thousand years—has led the Hungarian people
to the threshold of a still more splendid thousand years to
come!"
{37}
Writing shortly before the opening, the United States Consul

at Buda-Pesth, Mr. Hammond, gave the following description of
the plans and preparations then nearly complete: "The series
of official festivities will be diversified by those of a
social and popular character. These will be the
interparliamentary conference for international courts of
arbitration; the congress of journalists, with the view to
constitute an international journalistic union; international
congresses of art and history, of actors, tourists, athletes,
etc.; numerous national congresses embracing every
intellectual and material interest of the country, in which
the leading personages of all groups and branches of national
production, the highest authorities in the field of commerce,
industry, communication, etc., as well as those who are in the
forefront of the literary, spiritual, and philanthropic
movements of the country will take part.
"There is activity in all classes of Hungarian society, with a

view to carrying out the ingenious project of the artist Paul
Vágó—the great historical pageant. Several municipal bodies
have already promised their cooperation, while scores of men
and women, bearers of historic names, have declared their
readiness to take part at their own expense. All the costumes
of all the races and social classes who have inhabited this
country during ten centuries will pass before our eyes in this
beautiful cortege. The genius of the artist will call into life
in their descendants the warriors who conquered Pannonia under
Arpad, and, during the reign of Louis the Great, annexed to
this realm all the neighboring countries; all the dignitaries,
both civil and ecclesiastical, who, under Stephen the Saint, King
Kálman, and Mathias Corvinus, spread Christianity,
enlightenment, liberty, and wealth to the extreme confines of
this part of Europe; all the crusaders of Joannes Hunyady, who
drove back the Crescent for a century and thus defended
western civilization against eastern fanaticism; all the
kings, princes, noblemen, and poets of modern times who have
led the nation in her struggle for modern ideas. These
historical figures will be followed by their retainers or
surrounded by the popular types of the respective epochs. To
judge by the sketches of the artist, this pageant promises to
surpass anything that has hitherto been offered on similar
occasions.
"All these festivals will move, as it were, within the fixed

frame of the Millennial National Exhibition, which will cover
an area of 500,000 square meters (5,382,100 square feet) and
consist of 169 buildings and pavilions, erected at a total
cost (including private expenses) of 10,000,000 florins
($4,020,000). This exhibition is divided into two sections,
viz:
(1) The historical section, containing art treasures, relics,

and antiquities of the past, which will illustrate the
political, religious, military, and private life of each
principal period in the history of the nation. …
(2) The section of modern times will embrace everything offered
by similar exhibitions.
Nevertheless, the visitor's mind will here, too, be impressed

with the solemnity of the millennium and the enthusiasm
inspiring the nation at this momentous period of its history.
The programme embraces the national life in all its
manifestations. Not only will the present condition of Hungary
be laid open to general view, but the world will also be
impressed with the great progress Hungary has made since the
reestablishment of her constitution in 1867."
United States Consular Reports,

April, 1896.
By every possible arrangement of facilitation and cheapening,

a visit to the Exposition was placed within the means of all
the inhabitants of the kingdom; and especial provision was
made for bringing schools and teachers to receive the
object-lessons which it taught.
Among the ceremonies which attended the ending of the great

national festival, was the formal opening, at Orsova, of a
ship channel through the rocky obstructions that have been
known since the days when they troubled the Romans as the
"Iron Gates of the Danube."
Industrial combinations.
See (in this volume)

TRUSTS: IN EUROPEAN COUNTRIES.
The forces of feudalism and clericalism in Austria.
Austrian parties in the Reichsrath.
Their aims, character and relative strength.
Count Badeni's language decrees for Bohemia.
"In no European country have the forces of feudalism and

clericalism such an enormous influence as they have in
Austria. The Austrian nobility is supreme at Court and in the
upper branches of the Administration. In Hungary the small
nobility and landed gentry exercise a preponderating
influence, but they are a wide class and filled with the
national spirit. The Austrian nobility forms a narrow,
intensely exclusive and bigoted caste, whose only political
interest is the maintenance of its own class supremacy. The
large Protestant element in Hungary has in no small degree
contributed to the success of the Magyars, both in its effect
on the national character and by the secondary position to
which the mixture of creeds has relegated the Church. In
Austria the Church of Rome is all-powerful. The House of
Habsburg has always been bigotedly Catholic: Francis Joseph
himself was a pupil of the Jesuits. The triumph of the
reaction after 1848 was the establishment in 1855 of that
'written Canossa' the Concordat, which made the Church
absolute in all matters relating to education and marriage.
And even though the Concordat was got rid of in 1870, the
energies of the clerical party have been but little weakened.
The real explanation of the whole course of Austrian politics
lies in the interaction of the two conflicts—of reaction,
clerical or aristocratic, against liberalism, and of Slav
against German. …
"In March 1897 came the general elections, to which a special
interest was lent by the first appearance of the fifth class
of voters. The most striking feature of the elections was the
complete and final break up of the German Liberal party. … The
history of the German Liberal party has been one of a
continuous decline both in numbers and importance. It counted
200 members in 1873, 170 in 1879, 114 in 1885-1891, and only
77 out of a total of 425 in 1897. … Their political theories
are those of moderate constitutional liberalism as understood
on the Continent in the middle of the century—i. e. belief in
the efficacy of parliamentary government, in commercial and
industrial freedom, hostility to military bureaucracy and
clericalism. … The most radical group among them, the
Progressists, an offshoot of the last election, is about as
radical as the ordinary English Conservative of to-day. The
views of the Verfassungstreue Grossgrundbesitz are those of
the English Tory of fifty years ago.
{38}
"Of the fractions into which the Liberal party is now divided
the most important is the Deutsch Fortschrittliche, or
Progressive, which split off from the main body in November
1896. Its chief object was to direct a stronger opposition on
national and liberal lines to Count Badeni. Its 35 members are
almost exclusively recruited from Bohemia and Moravia. They
differ from the German 'Volkspartei' mainly in their refusal
to accept anti-Semitism, which would be both against their
liberal professions and their economic convictions as
representatives of the commercial and manufacturing classes.
The constitutional landowners (Verfassungstreue
Grossgrundbesitz, 30 seats) represent the most conservative
element of the old Liberal party. … The 12 members of the Free
German Union (Freie Deutsche Vereinigung) may perhaps consider
themselves the most authentic remnant of the great Liberal
party—it is their chief claim to distinction. The German
National or People's party (Deutsche Volkspartei, 43 seats)
first made its appearance at the elections of 1885. It
rejected the old idea of the Liberals that the Germans were
meant, as defenders of the State, to look to State interests
alone without regard to the fate of their own nationality, and
took up a more strictly national as well as a more democratic
attitude. It has also of late years included anti-Semitism in
its programme. Its main strength lies in the Alpine provinces,
where it heads the German national and Liberal opposition to
the Slovenes on the one side, and the German clericals on the
other. It is at present the largest of the German parties. …
"Least but not last of the German parties comes the little
group of five led by Schönerer and Wolf. Noisy, turbulent, and
reckless, this little body of extremists headed the
obstruction in the Reichsrath, the disorganised larger German
parties simply following in its wake. The object these men aim
at is the incorporation of German Austria in the German
Empire, the non-German parts being left to take care of
themselves. Both the German National party and Schönerer's
followers are anti-Semitic, but anti-Semitism only plays a
secondary part in their programme. The party that more
specially claims the title of anti-Semite is the Christian
Social (Christlich-Soziale, 27 seats). The growth of this
party in the last few years has been extraordinarily rapid. In
Dr. Lueger and Prince Alois Liechtenstein it has found leaders
who thoroughly understand the arts of exciting or humouring
the Viennese populace. … The characteristic feature of
Austrian anti-Semitism, besides the reaction against the
predominance of the ubiquitous Jew in commerce, journalism,
and the liberal professions, is that it represents the
opposition of the small tradesman or handicraftsman to the
increasing pressure of competition from the large Jewish shops
and the sweating system so frequently connected with them. The
economic theories of the party are of the crudest and most
mediæval kind; compulsory apprenticeship, restricted trade
guilds, penalties on stock exchange speculation, &c., form the
chief items of its programme. …
"The German Clericals and the Clerical Conservatives

(Katholische Volkspartei and Centrum) number some 37 votes
together; but their importance has always been increased by
the skilful and unscrupulous parliamentary tactics of the
party. The strength of the Clerical party lies in the ignorant
and devotedly pious peasantry of Upper Austria and the Alpine
provinces. The defence of agrarian interests is included in
its programme; but its only real object is the maintenance of
the moral and material power of the Church. Its policy looks
solely to the interests of the Vatican. …
"The best organised of the national parties is the Polish Club

(59 seats). It represents the national and social interests of
the Polish nobility and landed gentry. … Standing outside of
Austrian interests, they exercise a controlling voice in
Austrian affairs. The three-score well-drilled Polish votes
have helped the Government again and again to ride roughshod
over constitutional opposition. The partition of Poland has
thus avenged itself on one at least of its spoilers. The
Germans have long resented this outside interference which
permanently keeps them in a minority. … The Czechs are a party
of 60, and together with the 19 representatives of the Czech
landed aristocracy, form the largest group in the Reichsrath.
The Young Czech party began in the seventies as a reaction
against the Old Czech policy of passive resistance. In
contra-distinction to the Old Czechs, they also professed
radical and anti-clerical views in politics generally. … In
1897 the Old Czechs finally withdrew from the contest or were
merged in the victorious party. … Of the other nationalist
parties the most important is the Slav National Christian
Union (35 seats), comprising the Slovenes, Croatians, and some
of the more moderate Ruthenians from Galicia. Their programme
is mainly national, though tinged with clericalism; equality
of the Slav languages with German and Italian in mixed
districts; and ultimately a union of the southern Slavs in an
autonomous national province. The Italians are divided into 5
Clerical Italians from the Tirol and 14 Liberals from Trieste,
Istria, &c. The Tirolese Italians desire a division of the
Tirol into a German and an Italian part. …
"The most interesting, and in some ways the most respectable,

of all Austrian parties is the Socialist or Social Democratic
party (15 seats). It is the only one that fights for a living
political theory—German liberalism being to all intents and
purposes defunct—and not for mere national aggression. The
Social Democrats hold the whole national agitation to be an
hysterical dispute got up by professors, advocates, and other
ne'er-do-weels of the unemployed upper classes. … Their
support is derived from the working classes in the industrial
districts, and not least from the poorer Jews, who supply
socialism with many of its keenest apostles. …
"Altogether a most hopeless jumble of incoherent atoms is this

Austrian Reichsrath. The chariots driving four-ways on the
roof of the Houses of Parliament are a true symbol of the
nature of Austrian politics. To add to the confusion, all the
parties are headless. Able men and men of culture, there are a
good many in the House; but political leaders there are none.
The general tone of the House is undignified, and has been so
for some time. …
{39}
"On April 5, 1897, Count Badeni published the notorious

language decrees for Bohemia. This ordinance placed the Czech
language on an absolute equality with the German in all
governmental departments and in the law courts all over
Bohemia. … After 1901 all officials in every part of Bohemia
were to be obliged to know both languages. The refusal of the
Germans to admit the language spoken by 62 per cent. of the
population of Bohemia to an equality with their own is not
quite so preposterous as would at first sight appear. Without
subscribing to Professor Mommsen's somewhat insolent dicta
about 'inferior races,' one must admit that the Czech and
German languages do not stand on altogether the same footing.
German is a language spoken by some 60,000,000 of people, the
language of a great literature and a great commerce. Czech is
difficult, unpronounceable, and spoken by some 5,000,000 in
all. It must be remembered, too, that the two nations do not
really live together in Bohemia, but that the Germans live in
a broad belt all round the country, while the Czechs inhabit
the central plain. There is no more reason for a German
Bohemian to acquire Czech than there is for a citizen of
Edinburgh to make himself master of Gaelic. On the other hand,
every educated Czech naturally learns German, even in a purely
Czech-speaking district. … It must also be remembered that the
decrees, as such, were of doubtful constitutionality; the
language question was really a matter for the Legislature to
settle. The decrees at once produced a violent agitation among
the Germans, which rapidly spread from Bohemia over the whole
Empire."
The Internal Crisis in Austria-Hungary

(Edinburgh Review, July, 1898).
AUSTRIA-HUNGARY: A. D. 1897 (October-December).

Scenes in the Austrian Reichsrath described by Mark Twain.
"Here in Vienna in these closing days of 1897 one's blood gets

no chance to stagnate. The atmosphere is brimful of political
electricity. All conversation is political; every man is a
battery, with brushes overworn, and gives out blue sparks when
you set him going on the common topic. … Things have happened
here recently which would set any country but Austria on fire
from end to end, and upset the government to a certainty; but
no one feels confident that such results will follow here.
Here, apparently, one must wait and see what will happen, then
he will know, and not before; guessing is idle; guessing
cannot help the matter. This is what the wise tell you; they

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First Aid for the Psychiatry Clerkship,

Fourth Edition - eBook PDF

Tips on what to know to IMPRESS

LATHA GANTI, MD, MS, MBA, FACEP Sean M. Blitzstein, MD

eBook conversion by codeMantra

Chapter 1: How to Succeed in the Psychiatry Clerkship 1

Chapter 2: Examination and Diagnosis 11

Chapter 3: Psychotic Disorders 21

Chapter 4: Mood Disorders 33

Chapter 5: Anxiety, Obsessive-Compulsive, Trauma, and Stressor-Related Disorders 47

Chapter 6: Personality Disorders 63

Chapter 7: Substance-Related and Addictive Disorders 79

Chapter 8: Neurocognitive Disorders 97

Chapter 9: Geriatric Psychiatry 113

Chapter 10: Psychiatric Disorders in Children 121

Chapter 11: Dissociative Disorders 133

Chapter 12: Somatic Symptom and Factitious Disorders 139

Chapter 13: Impulse Control Disorders 145

Chapter 14: Eating Disorders 151

Chapter 15: Sleep-Wake Disorders 159

Chapter 16: Sexual Dysfunctions and Paraphilic Disorders 171

Chapter 17: Psychotherapies 179

Chapter 18: Psychopharmacology 189

Chapter 19: Forensic Psychiatry 209

How to Succeed in the

Why Spend Time on Psychiatry? 2 Keep Patient Information Handy 3

How to Behave on the Wards 2 Present Patient Information in an Organized Manner 3

Why Spend Time on Psychiatry?

Being aware of and understanding the features of mental dysfunction in psy-

Psychotropic medications are frequently prescribed in the general popula-

Because of the unique opportunity to spend a great deal of time interacting

How to Behave on the Wards

Always maintain professionalism and show the patients respect. Be respectful

■■ Regardless of your interest in psychiatry, take the rotation seriously.

Be enthusiastic and self-motivated. Volunteer to help with a procedure or a

Use a clipboard, notebook, or index cards to keep patient information, includ-

Here is a template for the “bullet” presentation:

“This is a [age]-year-old [gender] with a history of [major history such

The newly admitted patient generally deserves a longer presentation following

How to Prepare for the Clerkship (Shelf ) Exam

Other helpful studying strategies include:

STUDY WITH FRIENDS

STUDY IN A BRIGHT ROOM

Mental Status Exam

Appearance/Behavior: apparent age, attitude and cooperativeness, eye

Speech: rate, rhythm, volume, tone, articulation

Mood: patient’s subjective emotional state—depressed, anxious, sad,

Affect: objective emotional expression—euthymic, dysphoric, euphoric,

Thought process: logical/linear, circumstantial, tangential, flight of

Thought content: suicidal/homicidal ideation, delusions, preoccupa-

Perceptual disturbances: hallucinations, illusions, derealization, deper-

Fund of knowledge: current events

Abstract thought: interpretation of proverbs, analogies

Insight: patient’s awareness of his/her illness and need for treatment

Judgment: patient’s ability to approach his/her problems in an appropri-

Characteristics: acute onset, waxing/waning sensorium (worse at night),

Etiology: drugs (narcotics, benzodiazepines, anticholinergics, TCAs, ste-

Management: identify/correct underlying cause, simplify Rx regi-

Mini-Mental State Examination (MMSE)

What is the [year] [season] [date] [day] [month]? (1 pt. each)

Attention (5): Either serial 7s or “world” backwards (1 pt. for each

Mania (“DIG FAST”)

Suicide Risk (“SAD PERSONS”)

(hypnagogic hallucination) or upon awakening (hypnopompic hal