Psychiatric Disorders in Medical Practice: Specific Syndromes

CHAPTER 369 Psychiatric Disorders in Medical Practice

2305
Psychiatric disorders are defined as disorders of the psyche—that is, condi-

tions that affect thoughts, feelings, or behaviors. By definition, such mental
disturbances must be sufficient to produce significant distress in the patient
or impairment in role or other functioning. Because the pathogeneses of most
psychiatric disorders are incompletely understood, classification is based on
clinical syndromes that are defined by diagnostic criteria with high interrater
reliability because they emphasize discrete reportable or observable symptoms
and signs. Interestingly, however, many underlying pathophysiologic mecha-
nisms probably cut across these descriptive diagnostic categories, although
current knowledge of such mechanisms rarely directly informs predictions of
course or therapeutic decision making.1
Specific Syndromes
Because many psychiatric disorders result from the direct influence of neu-
rologic conditions, systemic diseases, or drugs on brain functioning, assessment
of any new or worsened psychiatric condition must include evaluation for
their potential contributions (Table 369-1). Delirium (Chapter 25) and demen-
tia (Chapter 374), which are neurocognitive disorders defined by impairment
in intellectual functions such as attention, memory, or language, are always
the result of neurologic abnormalities, systemic illnesses, or drugs. Although
intellectual impairment is the hallmark of neurocognitive disorders, these
369
conditions also may manifest as alterations in other aspects of mental status,
including mood, thought content, thought process, and behavior. If a non-
cognitive psychiatric syndrome is caused by an identifiable underlying condi-
PSYCHIATRIC DISORDERS tion, it is known as a secondary psychiatric disorder (e.g., “major depression
due to hypothyroidism”).
IN MEDICAL PRACTICE The major nonsecondary, noncognitive psychiatric syndromes (Table 369-2)
can coexist with multiple syndromes. For example, a patient suffering major
JEFFREY M. LYNESS depression with psychotic features may have depressive, anxiety, and psychotic
syndromes simultaneously. Addictive disorders are considered in Chapters
30 and 31.
OVERVIEW Comorbid Conditions in Psychiatry

Disorders in Psychiatry It is common for persons who suffer from mental disorders to meet the diag-
Psychiatric disorders, also known as mental illnesses, are extraordinarily common nostic criteria for more than one condition. Although such comorbidity may
and have a profound impact on well-being and functional status. Collectively, reflect the limitations of current approaches to diagnosis, psychiatric comor-
psychiatric disorders account for more aggregate disability than do those bidity influences the choices or sequence of indicated treatments and may
involving any other organ system, with depression alone being second only worsen the overall prognosis. Comorbidity with other medical conditions
to cardiovascular disorders. also is common, probably reflecting complex bidirectional causal relationships
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2305.e3
ABSTRACT KEYWORDS
Psychiatric disorders, also known as mental illnesses, affect thoughts, feelings, psychiatric disorders
or behaviors. Psychiatric disorders, which by definition must be sufficient to psychopathology
produce significant distress for the patient or impair the patient’s functioning, depression
are extraordinarily common and have a profound impact on well-being and bipolar disorder
functional status. Because the pathogeneses of most psychiatric disorders are anxiety disorders
incompletely understood, classification is based on clinical syndromes that schizophrenia
are defined by diagnostic criteria with high interrater reliability because they personality disorders
emphasize discrete reportable or observable symptoms and signs. This chapter
provides an overview of the major psychiatric disorders encountered in medical
practice, with the exception of those disorders considered in other chapters
(e.g., delirium, dementia, addictions).
2306 CHAPTER 369 Psychiatric Disorders in Medical Practice

between physical and mental illnesses, and such comorbidity also often worsens of treatment. Nonpharmacologic evidence-based somatic therapies include
the prognosis for both conditions. electroconvulsive therapy, light therapy, and vagal nerve stimulation for par-
ticular forms of major depression. Studies are ongoing regarding other methods
Treatments in Psychiatry for selected cases of severe depressive or obsessive-compulsive disorders,
Treatments in psychiatry are intended to reduce or eliminate symptoms, thereby including deep brain stimulation, transcranial direct-current stimulation, and
improving the patient’s distress and dysfunction and averting suicidal behavior. repetitive transcranial magnetic stimulation.
Maintenance therapies reduce the frequency or severity of recurrent episodes.
Pharmacotherapy remains an evidence-based mainstay of the treatment of Mood Disorders
many psychiatric conditions. The evidence for a number of forms of psycho- Mood disorders are categorized as either depressive (also termed unipolar),
therapy administered in individual, group, or family modalities also strongly characterized by depressive episodes only, or bipolar, characterized by manic
support their use as primary treatment or co-treatment of many conditions. or hypomanic episodes, typically with depressive episodes as well.
Other psychosocial interventions, ranging from self-help groups to the use of
structured treatment or residential programs, are often important components MAJOR DEPRESSIVE DISORDER
DEFINITION
Major depressive disorder is characterized by one or more episodes of idio-
TABLE 369-1 IMPORTANT CAUSES OF PSYCHIATRIC pathic major depressive syndrome (Table 369-3).
SYNDROMES
CENTRAL NERVOUS SYSTEM DISEASES
EPIDEMIOLOGY
In the United States major depression has a 12-month prevalence of approxi-
Trauma mately 7%, and it is at least 1.5 times more common in females than males,
Tumor only in part because of the 6 to 13% prevalence of postpartum depression.2
Toxins
Seizures Lifetime prevalence is up to 10% in males and 20 to 25% in females. New
Vascular depressive episodes have an annual incidence of approximately 3%. Depres-
Infections sion accounts for more than twice as much disability in midlife as any other
Genetic/congenital malformations medical condition, and its overall cumulative burden is greater than that from
Demyelinating diseases all but cardiovascular disorders. The economic impact is also enormous, with
Neurodegenerative diseases U.S. estimates of annual costs for depression exceeding $12 billion for treat-
Hydrocephalus ment, $8 billion for associated morbidity, and $33 billion for lost earnings
SYSTEMIC DISEASES and work productivity.
Cardiovascular
Pulmonary PATHOBIOLOGY
Endocrine Major depression is not a single disease entity but rather a heterogeneous
Metabolic group of conditions with multiple pathogenic mechanisms. It is both multi-
Nutritional
factorial and polygenic: genetic factors account for approximately 40% of the
Infections
Cancer risk for depression, but multiple gene loci, most of which are currently unknown,
are probably involved in a complex interplay with developmental and envi-
DRUGS (e.g., recreational, prescription, or over-the-counter drugs)
ronmental influences. Alterations in the brain’s noradrenergic and serotonergic
Drug intoxication systems are likely related to the efficacy of current antidepressant medications.
Drug withdrawal The hypothalamic-pituitary-adrenal axis is hyperactive in depression, as
TABLE 369-2 IMPORTANT PSYCHIATRIC SYNDROMES AND DISORDERS

SYNDROME MAIN SYMPTOMS AND SIGNS MAY OCCUR AS PART OF THESE DISORDERS
Neurocognitive Deficits in intellectual functions (e.g., level of consciousness, orientation, Neurocognitive disorders
attention, memory, language, praxis, visuospatial, executive functions) Intellectual disability (if onset in childhood)
Mood: depressive Lowered mood, anhedonia, negativistic thoughts, neurovegetative symptoms Neurocognitive disorders
Mood disorders (bipolar or depressive) (primary or secondary)
Psychotic disorders (schizoaffective disorder)
Mood: manic Elevated or irritable mood, grandiosity, goal-directed hyperactivity with increased Neurocognitive disorders
energy, pressured speech, decreased sleep need Bipolar disorder (primary or secondary)
Psychotic disorders (schizoaffective disorder)
Anxiety All include anxious mood and associated physiologic symptoms (e.g., palpitations, Neurocognitive disorders
tremors, diaphoresis); may include various types of dysfunctional thoughts Mood disorders (bipolar or depressive) (primary or secondary)
(e.g., catastrophic fears, obsessions, flashbacks) and behavior (e.g., compulsions, Psychotic disorders (primary or secondary)
avoidance behavior) Trauma- and stressor-related disorders
Anxiety disorders (primary or secondary)
Obsessive-compulsive and related disorders
Psychotic Impairments in reality testing: delusions, hallucinations, thought process Neurocognitive disorders
derailments Mood disorders (bipolar or depressive) (primary or secondary)
Psychotic disorders
Somatic symptom Somatic symptoms with associated distressing thoughts, feelings, or behaviors Mood disorders (bipolar or depressive) (primary or secondary)
syndromes Anxiety disorders (primary or secondary)
Obsessive-compulsive and related disorders
Trauma- and stressor-related disorders
Somatic symptom disorders
Personality pathology Enduring patterns of dysfunctional emotional regulation, thought patterns, Neurocognitive disorders (dementia)
interpersonal behavior, impulse regulation Personality change due to another medical condition
Personality disorders
Author summary based on categories and criteria from American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. (DSM-5) Washington, DC: American Psychiatric
Association; 2013.

2307
TABLE 369-3 SYMPTOMS/SIGNS OF AN EPISODE OF MAJOR TABLE 369-4 TREATMENTS FOR DEPRESSION
DEPRESSIVE SYNDROME NAME OF PSYCHOTHERAPY APPROACH
DIAGNOSTIC CRITERIA (a minimum of five symptoms must be present for a Cognitive psychotherapy Identify and correct negativistic patterns of
minimum of 2 consecutive weeks) thinking
Depressed mood (may be irritable mood in children and adolescents) most of the Interpersonal psychotherapy Identify and work through role transitions or
day, nearly every day, OR interpersonal losses, conflicts, or deficits
Markedly diminished interest or pleasure most of the day, nearly every day AND
Weight loss or gain, or change in appetite (decrease or increase) nearly every day Problem-solving therapy Identify and prioritize situational problems;
Change in sleep (insomnia or hypersomnia) nearly every day plan and implement strategies to deal
Psychomotor agitation or retardation nearly every day with top-priority problems
Fatigue or loss of energy nearly every day Psychodynamic psychotherapy Use therapeutic relationship to maximize use
Feeling of worthlessness or guilt nearly every day of the healthiest defense mechanisms and
Diminished concentration or indecisiveness nearly every day coping strategies
Recurrent thoughts of death or suicidal ideation, or a suicide attempt, or a specific
suicide plan
MNEMONIC TO AID RECALL OF DIAGNOSTIC CRITERIA: “SIG: E CAPS”
(i.e., prescribe energy capsules) for depressed mood
be seen without a depressed mood, albeit by definition they then must have
Sleep change loss of interest or pleasure in their usually desired activities. They may also
Interests decreased
Guilt
exhibit prominent anxiety, irritability, or somatization. Although the mildest
Energy decreased forms of major depression in the community may remit spontaneously within
Concentration decreased a few months without medical care, patients may have persistent symptoms
Appetite/weight disturbance for months or years, too often without seeking treatment.
Psychomotor changes
Suicide thoughts DIAGNOSIS
DEPRESSIVE SYMPTOMS/SIGNS GROUPED CONCEPTUALLY, WITH The diagnosis is made clinically by elicitation of findings from the history and
ADDITIONAL COMMON PHENOMENA mental status examination to determine the presence of major depressive
Emotional syndrome. The differential diagnosis includes other idiopathic disorders with
Depressed mood, sadness, tearfulness
episodes of major depression, such as bipolar disorder (distinguished by a
Irritability (seen in all ages, perhaps most commonly in children/adolescents and the history of manic episodes) and schizoaffective disorder (distinguished by a
elderly) history of psychotic episodes in the absence of depression). Major depression
Anxiety may accompany delirium or dementia, and secondary depression also com-
Loss of interests or pleasure (anhedonia) monly accompanies serious medical illnesses; these comorbid conditions
Ideational require careful, well-coordinated care. Screening instruments (see Table 24-3
Worthlessness/lowered self-esteem
in Chapter 24) can help identify cases of depression. For example, using the
Guilt two-item version of the Patient Health Questionnaire, the screener asks the
Hopelessness/nihilism patient the following questions: Over the past 2 weeks, how often have you
Helplessness (1) had little interest or pleasure in doing things, or (2) been feeling down,
Thoughts of death, dying, suicide depressed, or hopeless? Responses for each question are scored as follows: 0
Somatic/Neurovegetative = not at all, 1 = several days, 2 = more than half the days, 3 = nearly every
Change in appetite/weight
day. A score of 3 points or higher on the two-item screen is associated with
Change in sleep 75% probability of having a depressive disorder.
Anergia
Decreased libido
Trouble concentrating
Diurnal variation in symptoms (mornings—worst pattern is most characteristic) TREATMENT
Other
The three phases of treatment are (1) acute, in which treatment is provided
Ruminative thinking (tendency to dwell on one [negativistic] theme) to resolve the major depressive episode; (2) continuation, in which the acute
Somatic symptoms or somatic worry treatment is continued for 6 to 12 months to prevent relapse; and (3) mainte-
Psychotic symptoms (negativistic delusions most characteristic)—defines the nance, for those with two to three or more episodes of recurrent depression,
subtype “Major Depression with Psychotic Features” for whom treatment is maintained indefinitely to reduce the frequency and
Based on criteria from American Psychiatric Association. Diagnostic and Statistical Manual of Mental severity of future recurrences.3,4
Disorders. 5th ed. (DSM-5) Washington, DC: American Psychiatric Association; 2013. Acute treatment of depression includes focused psychotherapies (Table
369-4), which are more efficacious than usual care and equivalent to medica-
tions when used for patients in primary care settings. A1-A3 Based on the patient’s
preference, psychotherapy rather than medication may be the initial treatment
of mild to moderate major depression, perhaps especially for individuals with
evidenced by a nonsuppressed response to the dexamethasone suppression prominent psychosocial stressors. Involvement of family members for educa-
test, although this test is too insensitive and nonspecific for clinical use as a tion, support, and sometimes formal family therapy may be an important
diagnostic tool. Neuroimaging studies in subjects with depression show an adjunctive or primary therapeutic approach. These therapies may be admin-
array of findings, including smaller hippocampal volumes that may be the istered with decreased frequency during the continuation or maintenance
result of exposure to chronically elevated cortisol levels, and altered cerebral phases of treatment. However, psychotherapies alone are insufficient for more
metabolic activity in regions including frontal-striatal circuitry and the anterior severe forms of depression, including major depression with psychotic features.
cingulate cortex. Cognitive psychology studies have demonstrated dysfunc- Meta-analyses suggest that the combination of medication with psychotherapy
is more effective than medication alone in the initial treatment of mild to mod-
tional patterns of negative thinking, with distorted thoughts about self, the erate major depression. A4
future, and the environment. Poor quality or absence of social relationships, Medications should be used as initial treatment for most patients with more
and stressful life events, particularly events such as deaths, separations, or severe forms of major depression. Antidepressant medications (Table 369-5)
functional impairment, are powerfully associated with depression as well. are also effective for acute, continuation, and maintenance therapy. Overall
data suggest that no second-generation agent is predictably better than
CLINICAL MANIFESTATIONS others, A5 although agents targeting noradrenergic as well as serotonergic systems
may be more efficacious in more severe depression. Because antidepressant

The symptoms of depression (see Table 369-3) may be conceptually grouped

medications typically do not begin to improve symptoms for at least 1 to 2
as alterations in mood, ideation (i.e., thought content), and somatic/ weeks, with maximal benefit accruing up to at least 6 to 8 weeks, it is crucial
neurovegetative functioning. Importantly, patients with depressive illness may

TABLE 369-5 COMMONLY USED ANTIDEPRESSANT MEDICATIONS*

NAME OF CLASS/ IMMEDIATE MECHANISM OF INITIAL TARGET ADULT DOSE
SPECIFIC MEDICATION ACTION ADULT DOSE RANGE† SIDE EFFECTS COMMENTS
Selective serotonin Inhibit presynaptic reuptake of Nausea, diarrhea, sexual
reuptake inhibitors serotonin dysfunction, serotonin
(SSRIs) syndrome
Citalopram 20 mg daily 20-40 mg daily (maximum Risk of QTc prolongation/ Few drug-drug interactions
20 mg daily in patients torsade de pointes in
age >60 yr) at-risk patients
Escitalopram 10 mg daily 10-20 mg daily Enantiomer of citalopram
Fluoxetine 20 mg daily 20-40 mg daily Long half-life; tends to be
(depression), up to activating
80 mg daily (OCD)
Paroxetine 20 mg daily 20-50 mg daily Anticholinergic effects Tends to be sedating
Sertraline 25-50 mg daily 50-200 mg daily Few drug-drug interactions
Serotonin and Inhibit presynaptic reuptake of Nausea, diarrhea, serotonin
norepinephrine serotonin and norepinephrine syndrome, sinus
reuptake inhibitors tachycardia, mild elevation
(SNRIs) in blood pressure, tremor
Duloxetine 30-60 mg daily 30-60 mg daily on a
twice-daily schedule,
maximum of 120 mg/
day
Venlafaxine 37.5 mg bid 150-375 mg/day on bid XR form allows once-daily
schedule dosing
Desvenlafaxine 50 mg daily 50 mg daily, maximum of Metabolite of venlafaxine
100 mg ER daily
Tricyclic antidepressants Inhibit presynaptic reuptake of Anticholinergic effects,
(TCAs) serotonin and norepinephrine sedation, orthostatic
(in varying proportions hypotension, tremor,
depending on the specific cardiac conduction delays,
TCA) ventricular arrhythmias
Amitriptyline 25-75 mg qhs 150-300 mg qhs Strongly anticholinergic and
sedating; aim for combined
amitriptyline/nortriptyline
blood level of 120-250 ng/mL
Desipramine 25-75 mg daily 150-300 mg daily Aim for blood level of
115-250 ng/mL
Doxepin 25-75 mg qhs 150-300 mg qhs Strongly sedating
Imipramine 25-75 mg daily 150-300 mg daily Strongly anticholinergic; aim for
combined imipramine/
desipramine blood level of
180-350 ng/mL
Nortriptyline 25-50 mg qhs 50-150 mg qhs Aim for blood level of
50-150 ng/mL; least
anticholinergic of the TCAs
Monoamine oxidase Inhibit monoamine oxidase, the Need for tyramine-free diet
inhibitors (MAOIs) enzyme that catalyzes to avoid sympathomimetic
oxidative metabolism of (hypertensive) crisis;
monoamine neurotransmitters sedation, anticholinergic
effects, tremor, orthostatic
hypotension
Isocarboxazid 10 mg bid 20-60 mg/day in bid-qid
dosing
Phenelzine 15 mg tid 45-90 mg/day in tid or qid
dosing
Selegiline (selective MAO-B inhibitor) 5 mg bid 5 mg bid Tyramine-free diet not Take with meals
required
Tranylcypromine 10 mg tid 30-60 mg/day in tid dosing
Other
Bupropion Unknown, although it is a weak 75-150 mg/day 300-450 mg/day Activating; risk for seizures Divided dosing required unless
inhibitor of presynaptic reduced by divided dosing using SR or XL forms
reuptake of norepinephrine and careful dosage
and dopamine titration
Mirtazapine Antagonist at α2 and 5-HT2 15 mg qhs 30-45 mg qhs; maximum Sedation, hyperphagia Becomes more stimulating at
receptors of 45 mg qhs higher doses
Trazodone Inhibits presynaptic reuptake of 25-50 mg qhs 300-600 mg qhs for Sedation, priapism Few sexual side effects
serotonin; antagonist at 5-HT2 depression, 25-100 mg
and 5-HT3 receptors qhs for insomnia
Vilazodone Inhibits presynaptic reuptake of 10 mg daily 40 mg daily Nausea, diarrhea, sexual side Dosage must be increased slowly
serotonin; agonist at 5-HT1A effects
receptors
Vortioxetine Inhibits presynaptic reuptake of 10 mg daily 20 mg daily Nausea, diarrhea, sexual side
serotonin; agonist at 5-HT1A effects
receptors, antagonist at 5-HT3
receptors
*Patients on any of these medications must be monitored for suicidal thoughts.
†
Target doses in the elderly may be lower.
ER = extended release; 5-HT2 = 5-hydroxytryptamine; OCD = obsessive-compulsive disorder; qhs = at bedtime; SR = sustained release; XR = extended release.

2309
to see patients regularly (every 1 to 2 weeks initially) to monitor their clinical

status, provide support and education, and foster adherence. Antidepressant TABLE 369-6 SYMPTOMS/SIGNS OF AN EPISODE OF MANIA
medications appear to increase the relative risk for suicidal behavior in adoles- DIAGNOSTIC CRITERIA
cents and young adults, so such patients require careful benefit/risk assessments
and close monitoring. By comparison, the relative risk for suicidal behavior is A distinct period of abnormally, persistently elevated, expansive, or irritable mood;
not increased by drug treatment in individuals older than age 25 and is sub- and abnormally and persistently increased goal-directed activity or energy lasting
stantially lowered in older adults. For patients with a psychotic depression, the ≥1 week and present most of the day, nearly every day, AND
addition of an antipsychotic medication (see Table 369-12) to an antidepressant 3 or more of the following symptoms/signs (4 or more if the mood abnormality is
may be more efficacious than either alone. Growing evidence suggests that only irritability):
a single intravenous dose of ketamine may rapidly reduce severe depressive Inflated self-esteem/grandiosity
symptoms within 24 hours, A6 and esketamine nasal spray is FDA-approved Decreased need for sleep
for treatment-resistant depression. Electroconvulsive therapy is preferred for More talkative or pressure to keep talking
the most severe forms of major depression, including major depression with Subjective experience of racing thoughts or flight of ideas observed on examination
psychotic features, and is also used for depression refractory to other forms of Distractibility
treatment. Deep brain stimulation is an investigational therapy for otherwise Increase in goal-directed activity or psychomotor agitation
refractory depression. Overall evidence to date does not support the efficacy Excessive involvement in activities with a high potential for painful consequences
of repetitive transcranial magnetic stimulation for depression. MANIC SYMPTOMS/SIGNS GROUPED CONCEPTUALLY, WITH
Mindfulness-based cognitive therapy, behavioral activation, and maintenance ADDITIONAL COMMON PHENOMENA
antidepressant treatment can reduce the rate of relapsing or recurrent depres-
Emotional
sive symptoms, with approximately equal efficacy. A7 In highly recurrent depres-
sion, however, maintenance pharmacotherapy may have the best outcomes. Euphoria
Optimal care for depression in primary care and other treatment settings may Irritability
be enhanced by the use of collaborative care models, A8 although the lack of Labile affect
reimbursement mechanisms often limits their implementation. Ideational
Grandiosity
Somatic/Neurovegetative
PROGNOSIS Increased energy
Psychomotor agitation

Optimal guideline-based treatment of major depression results in full remis-

Decreased need for sleep
sion in up to 80% of patients, and the expectation is that patients with major Distractibility
depression will return to baseline functioning after resolution of the depressive
episodes. However, at least 50 to 70% of patients will suffer recurrent episodes, Other
up to 20% may experience chronic major depression, and many more will Goal-directed hyperactivity
achieve only partial remission with persistent lower-level symptoms because Pressured speech
of a variety of factors, including limited access to care, nonadherence, or insuf- Impaired judgment
Flight of ideas
ficiently assertive treatments. Psychotic symptoms (may include delusions, hallucinations, or derailment of
thought processes such as loose associations)—defines the subtype “mania with
BIPOLAR DISORDER psychotic features”
From Diagnostic and Statistical Manual of Mental Disorders. 5th ed. (DSM-5) Washington, DC:
DEFINITION AND EPIDEMIOLOGY American Psychiatric Association, 2013, with permission.
Bipolar disorder is characterized by recurrent episodes of idiopathic mania.
Most persons with bipolar disorder also have recurrent episodes of major
depression.
The 12-month prevalence of bipolar disorder is approximately 0.6%. Males As with major depression, the diagnosis is based on findings from the history
are affected slightly more often than females. The average age at first onset is and examination revealing a pattern of recurrent manic episodes (Table 369-6)
late adolescence or early adulthood. Childhood onset is possible, but diagnosis that are usually interspersed with major depressive episodes and cannot be
may be difficult because of symptomatic overlap with other conditions of explained by other medical conditions, medications, or other substances.
childhood, such as the attention-deficit/hyperactivity disorder. Onset in midlife Although persons with bipolar disorder may become psychotic while in manic
to late life is also possible, although most late-onset mania is secondary to or depressed states, a history of psychotic symptoms in the absence of mania
other medical conditions or drugs rather than idiopathic bipolar disorder. or depression indicates a diagnosis other than bipolar disorder. Manic and
depressive episodes may also be seen in the course of delirium (Chapter 25)
PATHOBIOLOGY and dementia (Chapter 374), in which case the psychiatric symptoms are
Even though the pathogenesis of bipolar disorder remains unclear, genetic accompanied by the neurocognitive impairment that is the hallmark of the
factors play a greater role than in unipolar depressive conditions. Heritability latter conditions.
has been traced to several specific loci in rare families, but genetic screening
is not yet clinically useful, and the gene associations have to date revealed no
unifying pathophysiologic themes. Most cases of bipolar disorder are polygenic
and multifactorial, with genetic factors accounting for approximately 50% of
the risk for the disorder. Dysregulation of the frontostriatal systems is probably TREATMENT
involved in the manifestations of the illness. Though not specific enough to The mainstay of treatment for bipolar disorder is mood stabilizer medica-
be diagnostic, structural neuroimaging studies show increased ventricular-brain tions to reduce the frequency and severity of recurrent manic and depressive
ratios suggestive of parenchymal atrophy. Phase advance of central circadian episodes.6 Mood stabilizers with substantial evidence base to support their use
rhythms can precipitate episodes of mania, so the decreased sleep need of include lithium (typical dose of 600 to 1500 mg/day or higher given in two or
persons with incipient mania may produce a vicious cycle in which phase- three divided doses as needed to achieve plasma levels of 0.6 to 1.2 mEq/L [up
advanced circadian cycles lead to a further decreased need for sleep, thereby to 1.4 mEq/L in acute mania]), valproic acid (typical dose of 500 to 1500 mg/
resulting in further phase advancement. Psychosocial stressors also often play day or higher as tolerated to achieve plasma levels of 50 to 100 µg/mL), and
carbamazepine (typical dose of 400 to 1200 mg/day as tolerated to achieve
a role in precipitating episodes of both mania and depression. plasma levels of 4 to 12 µg/mL). The combination of lithium plus valproate
is superior to valproate alone for prevention of relapses. Lithium treatment
CLINICAL MANIFESTATIONS AND DIAGNOSIS is, however, associated with a decline in renal function, hypothyroidism, and
The symptoms of mania include a distinct period of abnormally and persis- hypercalcemia, especially in patients with higher lithium concentrations.7 A
tently elevated (euphoric) or irritable mood; goal-directed hyperactivity, often number of other anticonvulsants have been tried but generally with less empirical
for pleasurable activities, with poor judgment that leads to long-lasting adverse support for their use, although lamotrigine (starting at 25 mg/day, maximum
financial, psychosocial, or medical consequences (e.g., sprees of spending, dose of 200 mg/day, titrated slowly to minimize the risk for Stevens-Johnson
syndrome) can be used for prophylaxis against depressive episodes. Several
sexual activity, or gambling); increased energy; decreased need for sleep; pres- second-generation antipsychotic medications have received approval by the
sured speech; and distractibility.5

U.S. Food and Drug Administration (FDA) for their mood-stabilizing proper-
ties, but their potential to precipitate metabolic syndrome (and to a lesser TABLE 369-7 TYPES OF ANXIETY DISORDERS
extent tardive dyskinesia) should limit their use as maintenance medications ANXIETY DISORDER MAJOR CLINICAL CHARACTERISTICS
to patients for whom other mood stabilizers are inefficacious or poorly toler-
ated. A9 For acute episodes of mania, second- or first-generation antipsychotics Panic disorder Recurrent unexpected panic attacks, typically with
are more rapidly efficacious than mood stabilizers, with doses similar to their anticipatory anxiety and avoidance behavior
use for acute psychosis (see Table 369-12). For acute treatment of depressive Generalized anxiety Excessive anxiety and worry, not meeting the criteria
episodes, antidepressants may be required, but they may precipitate mania. disorder for other anxiety disorders, lasting ≥6 months
Therefore patients should receive therapeutic doses of a mood stabilizer first,
Phobias:
and exposure to antidepressant medication should be for the minimum dose
Agoraphobia Anxiety about or avoidance of places or situations
and duration required. Electroconvulsive therapy is useful for refractory mania
from which escape might be difficult or
or depression and for patients with relative contraindications to medications,
embarrassing or in which help might not be
such as pregnancy.
available in the event of panic symptoms
Supportive psychotherapy fosters compliance with maintenance treatments
Social phobia (social Anxiety provoked by exposure to social situations,
and helps patients manage psychosocial stressors, thereby minimizing their
anxiety disorder) typically with ensuing avoidance behavior; may be
impact on precipitating mania or depression. A10 For acute treatment of bipolar
generalized (i.e., in response to many interpersonal
depression, evidence-based psychotherapies for unipolar depression also may
situations) or specific in response to a particular
be used.
social situation (e.g., using a public restroom,
public speaking)
Specific phobia Anxiety provoked by exposure to a specific feared
object or (nonsocial) situation, typically with
ensuing avoidance behavior
PROGNOSIS
Author summary based on categories and criteria from American Psychiatric Association. Diagnostic

Most patients with bipolar disorder return to baseline functioning between and Statistical Manual of Mental Disorders. 5th ed. (DSM-5) Washington, DC: American Psychiatric
episodes. Some patients may experience frequent debilitating episodes (known Association; 2013.
as “rapid cycling,” defined as four or more episodes per year), and others may
experience deterioration in overall functioning over time.
OTHER MOOD DISORDERS PATHOBIOLOGY

Although the diagnosis of chronic major depression should be made in patients Anxiety may be understood in part as inappropriate triggering of the stress
with long-lasting major depressive episodes, others may have chronic (≥2 response system, commonly referred to as the “fight-or-flight” response.
years) lower-level depressive symptoms known as persistent depressive disorder However, it is important to recognize that the responses involve a wide range
(dysthymia), which may be treated with a combination of antidepressant of cognitive, motor, neuroendocrine, and autonomic systems and thus are not
medication and psychotherapy. Other patients may have “less than major limited to manifestations of sympathetic nervous system activity. The “salience
depression” episodes of shorter duration, often referred to as subsyndromal network” is believed to play a crucial role in the neurobiologic coordination
or subthreshold depression. Broad psychotherapeutic interventions may prevent of anxiety. The amygdala receives excitatory glutamatergic input from several
progression to full-fledged major depression in such patients. Premenstrual cortical areas and from the thalamus, thereby allowing it to respond to a wide
dysphoric disorder manifests as cyclical depressive and anxiety symptoms variety of stimuli, including sensory input from the external world, as well as
that resolve in the week after menses and recur in the week before the onset stressors that are processed and recognized by cortical association areas. The
of menses; this is the only mood disorder that may respond to brief cyclical amygdala in turn projects to the many brain regions that subserve the clinical
administration of antidepressant medication. manifestations of the anxiety response, in part through its direct projections
Less severe bipolar-related disorders include bipolar II disorder, which is to the important centers of monoaminergic systems: dopaminergic neurons
characterized by episodes of hypomania (i.e., low-level manic symptoms without of the ventral tegmental area in the midbrain, noradrenergic neurons in the
substantial functional impairment and without psychosis) and episodes of locus coeruleus, and serotonergic neurons in the raphe nuclei.
major depression. Such patients typically seek care during depressive episodes From a cognitive psychology perspective, the pathogenesis of many anxiety
rather than during hypomania, but antidepressant medication may worsen disorders, particularly panic, may be understood as catastrophic misinterpreta-
the manic symptoms. It is therefore imperative to ask about a history of manic tions of normal somatic sensations. A vulnerable individual may become aware
or hypomanic symptoms in the evaluation of all patients with depression. of a normal or minimally abnormal body sensation, which is interpreted as
Cyclothymic disorder, which includes episodes of hypomania and low-level something concerning, thereby leading to sympathetic and other autonomic
depressive episodes, may be difficult to distinguish from the mood instability arousal, which in turn leads to further somatic sensations (e.g., tachycardia,
seen in cluster B personality disorders (see later). sweating) in what becomes a vicious cycle of thoughts and somatic symptoms.
ANXIETY DISORDERS CLINICAL MANIFESTATIONS

Most individuals experience one or more somatic symptoms (Table 369-8)
DEFINITION that accompany psychic anxiety, regardless of whether the anxiety is normal
The anxiety disorders (Table 369-7) are a group of conditions whose hallmark or part of a pathologic condition. Such somatic symptoms may be referable
is idiopathic anxiety, typically accompanied by psychological (i.e., thought to virtually every body organ system.
content) and somatic symptoms.8 Anxiety is a common accompanying symptom Many anxiety disorders include acute, discrete periods of symptoms known
in many other psychiatric disorders, but the primary anxiety disorders lack as panic attacks. In a panic attack, the patient experiences an abrupt surge in
the neurocognitive deficits, depressive or manic symptoms, or psychosis seen anxiety, fear-related thoughts, and somatic symptoms in the space of a few
in the other disorders. Trauma- and stressor-related and obsessive-compulsive minutes (“crescendo onset”). The acute symptoms resolve quickly, typically
disorders are classified separately from the anxiety disorders. within an hour or less.
EPIDEMIOLOGY Panic Disorder

Anxiety disorders are a worldwide problem. Panic disorder has a 12-month Panic disorder consists of recurrent panic attacks. Although some panic attacks
prevalence of 2 to 3%. Generalized anxiety disorder has a 12-month prevalence may be precipitated by situations known to be stressful, at least some attacks
of approximately 3%, and the phobias collectively have a prevalence of 10 to must be unexpected (“out of the blue”). Patients also exhibit anticipatory
15% in the adult population. Cumulatively, anxiety disorders may have the anxiety in which they experience ongoing psychic distress by worrying about
highest prevalence of all primary psychiatric disorders in primary care settings. their next panic attack or the attack’s effects (e.g., humiliation if the attack
Clear data on incidence rates are not available. Primary anxiety disorders were to happen in public view). In addition, patients manifest avoidance
typically begin in adolescence through the mid-30s. Most anxiety symptoms behavior by staying away from known triggers or from situations in which
with new onset in later life are due to mood or neurocognitive disorders or having a panic attack might be dangerous (e.g., driving) or particularly dis-
are secondary to medical illnesses or drugs; true late-onset primary anxiety tressing (e.g., in public spaces). For many patients, the anticipatory anxiety
disorders are often triggered by traumatic or other stressful life events. and avoidance behavior may be more disabling than the panic attacks

2311
themselves. Avoidance behavior may overlap with agoraphobia, which is defined the stimulus whenever possible or endures the stimulus with considerable
as a distressing and disabling fear of places or situations from which escape distress. In addition to agoraphobia, the other main types of phobias are social
might be difficult or embarrassing or from which help might not be available phobia (social anxiety disorder)10 and specific phobias (see Table 369-7).
in the event of panic-like symptoms. Common agoraphobic foci include being
outside one’s home alone, being on bridges or in tunnels, traveling by vehicle, DIAGNOSIS
or being in crowds or lines. A third or more of patients with panic disorder Diagnosis of anxiety disorders must rest on consideration of both syn-
have comorbid agoraphobia, whereas others have agoraphobia alone or comor- dromic and etiologic perspectives. From a syndromic perspective, a careful
bid with other conditions. history and mental status examination are required to determine the pattern of
anxiety and associated symptoms and to determine whether the phenomenol-
Generalized Anxiety Disorder ogy fits the pattern for any of the anxiety disorders as described earlier. The
This more heterogeneous condition is defined by the presence of clinically history and mental status examination must also assess for the presence of
significant anxiety and associated somatic symptoms for 6 or more months. any other psychiatric disorder that might truly be comorbid with the anxiety
Generalized anxiety disorder9 is often overridden in the diagnostic hierarchy disorder but might also supersede the anxiety disorder in the diagnostic hier-
by other conditions that produce anxiety. archy. For example, generalized anxiety may be seen as part of neurocognitive
disorders (delirium or dementia), depressive or bipolar disorders, and psychotic
Social Anxiety and Phobias disorders.
The phobias are a group of conditions defined by the consistent ability of a From an etiologic perspective, it is important to determine whether the
specific environmental stimulus to elicit a pathologic anxiety response. Exposure anxiety disorder is primary (idiopathic) or secondary to a systemic or neuro-
to such a stimulus nearly always produces this response, so the patient avoids logic condition (see Table 369-1), drug intoxication, or withdrawal state. The
evaluation should include laboratory tests (e.g., toxic drug screen) as guided
by the differential diagnosis generated from the clinical evaluation.
TABLE 369-8 COMMON SOMATIC MANIFESTATIONS OF

ANXIETY
CARDIORESPIRATORY TREATMENT
Palpitations
Chest pain Empirical evidence from controlled trials demonstrates the efficacy of cog-
Dyspnea or sensation of being smothered nitive-behavioral psychotherapies for most of the anxiety disorders. A11 Such
GASTROINTESTINAL therapies, which use the principles of learning theory to extinguish unhelpful
behavior and positively reinforce more functional behavior, help the patient
Sensation of choking learn to identify and correct the dysfunctional patterns of thinking (“automatic
Dyspepsia thoughts”) that underlie or trigger the cognitive-physiologic cascade of patho-
Nausea logic anxiety responses. Cognitive behavioral therapy may be used as sole
Diarrhea therapy, particularly for specific phobias, or in combination with pharmaco-
Abdominal bloating or pain therapy. Frequently, cognitive behavioral therapy may be administered as part
GENITOURINARY of family therapy (e.g., to help family members avoid behavior that inadvertently
reinforces the patient’s symptoms) or in group therapy settings.
Urinary frequency or urgency Although anxiolytic drugs such as the benzodiazepines (Table 369-9) will
NEUROLOGIC/AUTONOMIC usually relieve acute anxiety symptoms, concerns about their long-term efficacy
Diaphoresis and side effects (e.g., risk for abuse, risk for neurocognitive impairment or falls)
Warm flushes or chills make antidepressant medications the more attractive pharmacologic agents
Dizziness or presyncope for most anxiety disorders (see Table 369-5). A12 Most antidepressants, with the
Paresthesias probable exception of bupropion, are helpful for panic disorder, generalized
Tremor anxiety disorder, and social phobia.
Headache
TABLE 369-9 SELECTED ANTIANXIETY AND HYPNOTIC DRUGS*

DRUG TRADE NAME INITIAL DOSE TARGET DOSE RANGE† SIDE EFFECTS COMMENTS
Benzodiazepines Sedation, ataxia, risk for falls Potential for abuse/dependence
Lorazepam Ativan 0.5 mg bid-qid 2-6 mg/day, tid-qid dosing Reliable IM absorption
Diazepam Valium 2-5 mg bid-tid 10-40 mg/day, bid-tid dosing Long half-life of drug and active metabolites
Triazolam Halcion 0.125 mg qhs 0.125-0.25 mg qhs Rebound insomnia Used as hypnotic
Chlordiazepoxide Librium 5 mg bid-tid 10-40 mg/day, bid-tid dosing Long half-life of drug and active metabolites
Temazepam Restoril 7.5 mg qhs 7.5-30 mg qhs Used as hypnotic
Alprazolam Xanax 0.25 mg tid-qid 2-8 mg/day, tid-qid dosing Possibly greater addictive potential
Clorazepate Tranxene 7.5-15 mg bid-tid 15-60 mg/day, bid-tid dosing
Flurazepam Dalmane 15-30 mg qhs 15-30 mg qhs Daytime somnolence Used as hypnotic
Oxazepam Serax 10-15 mg tid-qid 10-30 mg tid-qid
Clonazepam Klonopin 0.5 mg bid-tid 0.5-5 mg bid-tid Long duration of action
Zaleplon Sonata 5-10 mg qhs 5-20 mg qhs “Nonbenzodiazepine” hypnotic
Zolpidem Ambien 5-10 mg qhs 5-10 mg qhs “Nonbenzodiazepine” hypnotic
Eszopiclone Lunesta 1-2 mg qhs 1-3 mg qhs “Nonbenzodiazepine” hypnotic
β-Blockers
Propranolol Inderal 20 mg bid Individualize, 40-120 mg/day Bradycardia, hypotension, Only helps with sympathetically mediated
potential for mental slowing somatic symptoms of anxiety
*Antidepressants (see Table 369-5) are often first-line agents of choice for primary anxiety disorders.
†
qhs = at bedtime.

TABLE 369-10 COMMON TYPES OF OBSESSIONS AND Acute Stress Disorder and Post-Traumatic Stress Disorder
COMPULSIONS IN OBSESSIVE-COMPULSIVE Acute stress disorder and post-traumatic stress disorder (PTSD) are specific
DISORDER manifestations of symptoms referable to an extremely traumatic event. The
event by definition must involve exposure to actual or threatened death, serious
OBSESSIONS
injury, or sexual violence, as reported directly by the patient or by family
Aggressive (fears of harming self or others, of blurting out obscenities, or of other members or friends. Patients suffer from repeated or extreme exposure to
unwanted aggressive acts; unwanted violent or horrific images)
Contamination (concerns about dirt, germs, body waste or secretions, environmental
aversive details of the event. It is important to recognize that acute stress
contaminants, or animals/insects) disorder or PTSD does not develop in all individuals exposed to a single
Sexual (concerns about unwanted sexual images or impulses) traumatic event (e.g., a natural or man-made disaster). Some individuals may
Hoarding/saving instead develop other anxiety disorders, major depression, mania, or psychosis,
Religious (scrupulosity) (excessive concerns about sacrilege, blasphemy, right/wrong, and many may never develop diagnosable psychopathology.
morality) PTSD symptoms by definition persist for more than 1 month after the
Need for symmetry/exactness traumatic event and include the following types of clinical phenomena: (1)
Somatic (excessive concern about illness, body part, or appearance) intrusion, such as intrusive memories, dreams, flashbacks, or intensely dis-
COMPULSIONS tressing psychological or physiologic responses to reminders of the trauma;
Cleaning/washing (excessive or ritualized handwashing, showering, or other (2) avoidance of distressing memories or external reminders of the trauma;
grooming) (3) negative cognitions and mood, such as amnesia for aspects of the event,
Checking (checking locks, stove, appliances; checking body in relation to somatic negativistic thoughts about oneself in general or blame related to the event,
obsessions; checking that did not or will not harm self or others) persistent negative emotions, diminished interests or activities, or feelings
Repeating rituals (rereading or rewriting; routine activities such as going through a
door or arising from a chair)
of detachment; and (4) alterations in arousal and reactivity.14 Acute stress
Counting disorder by definition resolves in less than 1 month, with symptoms of intrusion,
Ordering/arranging avoidance, or arousal as well as negative mood or dissociative symptoms (e.g.,
Hoarding/saving “in a daze”).
Adapted from Goodman WK, Price LH, Rasmussen SA, et al. The Yale-Brown Obsessive The 12-month prevalence of PTSD in the United States is about 3%, with
Compulsive Scale. I. Development, use, and reliability. Arch Gen Psychiatry. 1989;46:1006-1011. projected lifetime risk approaching 9%. About half of adults with PTSD have
complete recovery within 3 months, but PTSD may persist for many months or
years. Both cognitive-behavioral and psychodynamic psychology perspectives
are useful in informing psychotherapeutic treatments. A13 Antidepressants also
have demonstrated efficacy in PTSD. Ketamine (0.5 mg/kg intravenously)
PROGNOSIS can provide rapid relief in patients with chronic PTSD. A14 Other agents have
In general, most persons with ongoing anxiety disorders tend to have a chronic been used as well, including prazosin (primarily for nightmares and insomnia)
course of waxing and waning symptoms. Maintenance therapies should often and second-generation antipsychotics, such as risperidone and quetiapine.
be used for patients with more chronic anxiety disorders, although evidence
to support long-term therapies is not as robust as for mood and psychotic PSYCHOTIC DISORDERS
disorders. Psychotic symptoms, defined as a loss of reality testing, include delusions (fixed
false beliefs), hallucinations (false sensory perceptions), and major derailments
Obsessive-Compulsive Disorder in thought processes (e.g., loose associations). Psychotic symptoms may be seen
Although anxiety is often prominent in obsessive-compulsive disorder (OCD), in the course of neurocognitive, secondary, and mood disorders. The psychotic
OCD has a distinct pathogenesis that is likely more closely related to other disorders are defined by the presence of psychotic symptoms in the absence
conditions such as body dysmorphic disorder, hoarding disorder, trichotil- of prominent mood disturbance or of neurocognitive deficits consistent with
lomania (hair-pulling), and excoriation (skin-picking) disorder. delirium or dementia. In general, the diagnosis and treatment of patients with
Patients with OCD have recurrent obsessions or compulsions (Table 369-10), psychotic disorders should be conducted in mental health specialty settings,
and most patients have both. OCD should not be confused with obsessive- but primary care settings are common points of entry to care.
compulsive personality traits or disorder, described later under “Personality
Disorders.” Obsessions, not to be confused with obsessing (ruminating) on Schizophrenia
a topic, are recurrent, persistent, and typically distressing thoughts that at DEFINITION AND EPIDEMIOLOGY
some point during the course of the disorder are experienced as intrusive and Schizophrenia, the prototypical psychotic disorder, necessarily includes symp-
unwanted. The latter quality may be described in language such as “I don’t toms of psychosis (“positive” symptoms) and also often includes “negative
know where this thought comes from” or “I don’t know why I have this thought, symptoms” such as affective flattening, abulia, apathy, and social withdrawal.
I would never actually do such a thing!” Compulsions are repetitive behaviors The level of functioning is impaired in one or more realms (e.g., occupational,
or mental acts the individual feels driven to perform in response to an obses- interpersonal, or self-care). The lifetime prevalence of schizophrenia is slightly
sion or according to rigid rules. For example, compulsive handwashing may less than 1%, and its chronic debilitating course takes a considerable toll on
relate to obsessional thoughts about germs or contamination. Patients with patients, families, and society. Peak onset is in late adolescence to young adult-
OCD typically attempt to ignore, suppress, or neutralize their obsessions, but hood, slightly younger for males than females. The annual incidence is approxi-
doing so causes great psychic distress. OCD patients may spend many hours mately 15 per 100,000, but with marked variability across study samples and
per day related to their obsessions and compulsions. populations. When narrowly defined as above, the condition is slightly more
The 12-month prevalence of OCD is approximately 1%, with onset typically common in males than in females.
in childhood, adolescence, or young adulthood. Remission rates are low in
adults, with most persons experiencing a chronic waxing and waning course. PATHOBIOLOGY
Pathogenesis probably involves altered functioning of the striatofrontal systems, The pathogenesis of schizophrenia remains unknown. Twin studies show that
as well as a prominent role for central serotonergic systems. Obsessions and the disease is multifactorial. Genetic factors account for up to 50% of the risk,
compulsions may represent inappropriate triggering of neural “scripts” involv- and multiple gene loci appear to be involved. Studies of postmortem brains
ing thoughts and behaviors that have been analogized to the scripts involved indicate a nongliotic neuropathologic process with subtle disruptions of corti-
in animal grooming and other complex but stereotypical behaviors. cal cytoarchitecture. It is likely that psychosocial factors and neurodevelopment
The only efficacious antidepressants in OCD are those with strong activity interact with a nonlocalizable brain “lesion” that is either present at birth or
on serotonergic systems, such as the selective serotonin reuptake inhibitors acquired early in life. Dopaminergic mesocortical and mesolimbic pathways
and the tricyclic compound clomipramine. Cognitive-behavioral therapies as well as glutamatergic systems are important in the production of psychotic
also have well-demonstrated efficacy, often in combination with pharmaco- symptoms.
therapy.11 Deep brain stimulation12 targeting the ventral capsule/ventral striatum
is FDA approved (as a humanitarian device exemption) for severe treatment- DIAGNOSIS
refractory OCD, although its precise role remains to be determined. Focused The diagnosis of schizophrenia is based on the presence of delusions, hallu-
ultrasound is another experimental possibility in refractory cases.13 cinations, and disorganized speech and behavior, often accompanied by apathy

2313
and social withdrawal and resulting in major impairment in functioning for
at least 6 months (Table 369-11).15 In patients with single schizophrenia-like TREATMENT
psychotic episodes of briefer duration, with subsequent return to asymptomatic
baseline functioning, brief psychotic disorder (<1 month) or schizophreniform Antipsychotic medications (Table 369-12), often with adjunctive benzo-
diazepines, are used to treat acute psychotic episodes, commonly in acute
disorder (1 to 6 months) is diagnosed.
inpatient settings so that the patient can be managed safely until the acute
symptoms improve.16 Although maintenance antipsychotic medications help
reduce the severity and frequency of acute psychotic episodes, comprehensive
psychosocial rehabilitation programs are required to improve functional out-
TABLE 369-11 SYMPTOMS AND SIGNS OF MAJOR comes; assertive use of such programs after first-onset psychosis may improve
PSYCHOTIC DISORDERS the longer-term course of the illness. Second-generation (“atypical”) antipsy-
chotic medications have replaced first-generation antipsychotics in common U.S.
SCHIZOPHRENIA
practice because of their lower rates of extrapyramidal side effects, including
Delusions tardive dyskinesia, although their efficacy is generally not better than that of
Hallucinations first-generation drugs. A15 However, second-generation drugs contribute to the
Disorganized speech (i.e., thought process derailments) increase in obesity and metabolic syndrome in patients with chronic schizo-
Grossly disorganized or catatonic behavior phrenia (Chapter 406).17 A large trial found that clozapine and long-acting
Negative symptoms: affective flattening, alogia, avolition injectable antipsychotics are associated with the greatest reduction in relapse
Major impairment in social or occupational functioning rates. A16 Data suggest that cariprazine, a new-generation antipsychotic, is
Duration of at least 6 months preferable to risperidone for patients with predominantly negative symptoms
SCHIZOAFFECTIVE DISORDER (withdrawal, apathy, etc.). A17
During the course of illness, at least one episode of schizophrenia-like psychotic

symptoms with a mood syndrome (either major depression or mania), AND
During the course of illness, at least 2 weeks of schizophrenia-like psychotic PROGNOSIS
symptoms in the absence of a mood syndrome The prognosis of individuals with schizophrenia is often poor, with recurrent
DELUSIONAL DISORDER episodes of psychotic exacerbations superimposed on progressively deteriorat-
One or more delusions for at least 1 month, most often nonbizarre (i.e., potentially ing baseline functioning. However, antipsychotic drugs significantly reduce
plausible, such as delusions of being followed, poisoned, infected, loved at a relapse rates. Some patients have a more favorable course, and a small propor-
distance, deceived by a spouse or lover, or having a disease) tion of individuals may recover completely. Male sex, prominent negative
Not meeting full criteria for an acute episode of schizophrenia symptoms, younger age at first onset, and enduring psychosocial stressors
Functioning not markedly impaired other than as related to the impact of the and family discord all predict poorer outcomes. Average life expectancy is
delusion(s) and its ramifications shortened by 10 to 15 years because of poor health behaviors, higher rates of
Based on criteria from American Psychiatric Association. Diagnostic and Statistical Manual of Mental other medical disorders (including metabolic syndrome), and a lifetime suicide
Disorders. 5th ed. (DSM-5) Washington, DC: American Psychiatric Association; 2013.
risk of approximately 5 to 6%.
TABLE 369-12 COMMONLY USED ANTIPSYCHOTIC MEDICATIONS

INITIAL DOSE FOR TARGET DOSE FOR CHLORPROMAZINE DOSAGE
PSYCHOSIS IN PSYCHOSIS IN EQUIVALENCE (FIRST-GENERATION
DRUG NAME SCHIZOPHRENIA* SCHIZOPHRENIA† SIDE EFFECTS DRUGS ONLY)/OTHER COMMENTS
First-generation drugs Low-potency drugs: anticholinergic effects,
orthostatic hypotension, prolongation of
QT interval, cholestatic jaundice
High-potency drugs: extrapyramidal side
effects (dystonias, akathisia, parkinsonism,
neuroleptic malignant syndrome),
hyperprolactinemia with galactorrhea
Chlorpromazine 100 mg qd 300-1000 mg/day, qd-bid dosing 100 mg
Thioridazine 50-100 mg qd 300-800 mg/day, qd-bid dosing Pigmentary retinopathy at higher doses 100 mg
Thiothixene 2-5 mg qd 5-60 mg/day, qd-bid dosing 5 mg
Trifluoperazine 2-5 mg qd 5-40 mg/day, qd-bid dosing 5 mg
Perphenazine 4-8 mg qd 8-64 mg/day, qd-tid dosing 8 mg
Haloperidol 0.5-2 mg qd 2-10 mg/day (up to 40 mg/day 2 mg; available in depot IM form
or higher in refractory cases),
qd-bid dosing
Fluphenazine 1-2.5 mg qd 2.5-10 mg/day (up to 40 mg/day 2 mg; available in depot IM form
in refractory cases), qd-bid
dosing
Second-generation drugs Metabolic syndrome, risk for stroke and
mortality in older patients with dementia,
QT prolongation
Risperidone 0.5-1 mg qd-bid 2-4 mg/day, qd-bid dosing Extrapyramidal side effects at higher doses Available in depot IM form
Olanzapine 5 mg qd 5-10 mg qd (up to 20 mg/day in
refractory cases)
Ziprasidone 20 mg bid 20-80 mg bid
Quetiapine 25-50 mg bid-tid 300-800 mg/day, bid-tid dosing Extended-release form for qd dosing
Asenapine 5 mg bid 5-10 mg bid Sublingual form only
Paliperidone 3-6 mg qd 6-12 mg qd
Iloperidone 1 mg bid 2-12 mg bid
Lurasidone 40 mg qd 40-160 mg qd
Aripiprazole 10-15 mg qd 10-30 mg qd Partial agonist/antagonist at D2 receptors
Clozapine 12.5 mg qd-bid 300-900 mg/day, qd-bid (titrate Risk for agranulocytosis, requires ongoing Efficacy superior to that of other
dose slowly by 25-50 mg/day monitoring of complete blood count antipsychotics, but hematologic risks
every 3-7 days) and need for monitoring limit its use
*Doses for other indications, such as agitation in delirium or dementia, may be much lower.
†

Schizoaffective Disorder TREATMENT

Schizoaffective disorder is a chronic recurrent disorder with a lifetime preva-
lence of approximately 0.3%. It is characterized by episodes of psychosis in Management of patients with somatic symptom disorders is often difficult
because physicians must simultaneously maintain an appropriate level of vigi-
the absence of mania or depression, and also by mood episodes (manic or
lance for undiagnosed physical illness while avoiding unnecessary interventions.
depressed) with psychotic features. As a result, the diagnosis of schizoaffective Keys to ongoing care include maintaining an ongoing therapeutic alliance,
disorder requires knowledge of the patient’s course over time and cannot be setting regular office visits, conveying empathy for the patient’s very real distress
based on the patient’s clinical findings at any one point in time. Treatment is without colluding with the patient’s belief in an identifiable physical disorder,
symptomatic and involves the use of antipsychotic medications (see Table and assertively treating depression, anxiety, or other comorbid psychopathol-
369-12), mood stabilizers (see the Treatment box for bipolar disorders), and ogy. Antidepressant medications may benefit selected patients (e.g., some
antidepressant medications (see Table 369-5) to target specific psychotic and chronic pain syndromes), even in the absence of other comorbid psychiatric
mood symptoms. The outcomes of schizoaffective disorder are heterogeneous disorders.
but on average intermediate between those of schizophrenia and mood
disorders.
Delusional Disorder
Delusional disorders are characterized by one or more delusions in the absence PERSONALITY DISORDERS
of a thought process disorder, prominent hallucinations, or the negative symp- Personality is defined as the repertoire of enduring patterns of inner mental
toms seen in schizophrenia. The most characteristic types of delusions are experience and behavior, including affect and impulse regulation, defense and
potentially plausible (“nonbizarre”), such as unfounded beliefs of a partner’s coping mechanisms, and interpersonal relatedness. Dimensional models of
infidelity. Delusional disorder has a lifetime prevalence of approximately 0.2%. personality (i.e., using multiple continuous measures of constructs such as
The pathogenesis of delusional disorder remains largely unknown. It is often neuroticism, extraversion, and openness to experience) likely are a more accu-
only partially responsive to antipsychotic medications (see Table 369-12), rate representation of the spectrum of human personality, but categorical
but patients’ functioning may be largely unimpaired if they are able, with the diagnostic categories (i.e., personality disorders) are more useful for clinicians
aid of antipsychotics and psychotherapy, to avoid acting on their delusions. to determine prognosis and treatments.18 Personality and personality disorders
are the result of complex interactions among genetic, environmental, and
SOMATIC SYMPTOM AND RELATED DISORDERS developmental factors. The cumulative point prevalence of all personality
Formerly termed somatoform disorders, the somatic symptom disorders include disorders in the general adult population is approximately 10 to 15%, with
both somatic symptoms and associated thoughts, feelings, or behaviors that rates as high as 50% in patients receiving care in psychiatric treatment
are distressing and disabling (Table 369-13). Although identifiable physical settings.
disease is insufficient to explain the patient’s presentation fully, in all these
conditions (other than factitious disorder) the patient’s distress and dysfunc- CLINICAL MANIFESTATIONS AND DIAGNOSIS
tion are not consciously produced and thus are just as distressing and baffling A personality disorder is diagnosed when enduring personality traits lead to
to patients as would be similar symptoms produced by physical disease. Malin- pervasive (if variable) distress or dysfunction in a range of situations (Table
gering is the conscious feigning of illness for conscious gain and is therefore 369-14). In diagnosing personality disorders, care must be taken to distinguish
not considered to be a mental disorder at all. personality traits, which by definition are enduring, from time-limited states.
Most persons can regress to less adaptive personality styles not characteristic
of their baseline personality traits in the context of substantial psychosocial
stressors.
TABLE 369-13 SOMATIC SYMPTOM AND RELATED TREATMENT

DISORDERS
In many affected individuals, trying to alter the fundamental personality
TYPE MAIN CLINICAL MANIFESTATIONS structure is not a realistic goal. Instead, a more realistic goal is to help patients
Somatic symptom disorder One or more distressing somatic symptoms, together maximize use of their personality strengths while minimizing the harmful effects
with excessive thoughts, feelings, or behaviors of emotional dysregulation, dysfunctional defenses, and destructive behavior.
related to these symptoms; subsumes most of the Dialectic behavior therapy is an evidence-based, focused psychotherapy based
former terms somatization disorder, pain disorder, on specific cognitive-behavioral techniques that reduce self-injurious behavior
undifferentiated somatoform disorder, and many and suicidality in patients with borderline personality disorder.
with the former diagnosis of hypochondriasis Although pharmacotherapy is not the mainstay of treatment of most personal-
ity disorders, drugs can be useful in selected patients. Antipsychotic drugs may
Illness anxiety disorder Illness preoccupation and excessive health-related be used to target escalating paranoia in paranoid personality disorder or for
behaviors in the absence of or disproportionate to short-term reduction in emotional and impulse regulation with a wide range
somatic symptoms; subsumes some patients with of (often cluster B, see Table 369-14) personality disorders in times of crisis.
the former diagnosis of hypochondriasis For longer-term treatment of emotional dysregulation in borderline and other
Conversion disorder Neurologic somatoform symptoms (other than pain) cluster B personality disorders, mood stabilizers or antidepressants may be used.
(functional neurologic with clinical evidence incompatible with recognized
symptom disorder) neurologic or general medical conditions (e.g.,
paralysis, blindness, dyscoordination, convulsion-
like phenomena, memory or other neurocognitive
complaints)
SUICIDE AND EVALUATION OF SUICIDALITY
Psychological factors Psychological factors adversely affecting a (non–
affecting other medical mental disorder) medical symptom or condition by Suicide is a leading cause of death worldwide.19 Suicide rates in the United
conditions worsening the course, interfering with treatment, States average approximately 11 per 100,000 per year, with considerable vari-
adding to known health risks, or influencing ability geographically and demographically. Of all age-, gender-, and race-based
underlying pathophysiology demographic groups, the highest U.S. suicide rates occur in older white men,
Factitious disorder Falsification of physical or psychological signs or while suicide is the third leading cause of death in adolescents and young
(commonly called symptoms, with health- or help-seeking behaviors, adults and the tenth leading cause of death in the population overall. Suicide
Munchausen syndrome) in the absence of clear external rewards attempts, more than 10 times more common than death by suicide, lead to
Author summary based on criteria from American Psychiatric Association. Diagnostic and Statistical considerable morbidity and utilization of health care resources.
Manual of Mental Disorders. 5th ed. (DSM-5) Washington, DC: American Psychiatric Association; Suicide is a potentially preventable cause of death, but despite considerable
2013.
research on risks for suicidal behavior, specific predictions about an individual’s

2315
TABLE 369-14 PERSONALITY DISORDERS TABLE 369-16 GENERAL CONSIDERATIONS IN DECIDING TO

TYPE OF PERSONALITY REFER A PATIENT FOR PSYCHIATRIC
DISORDER MAIN IDENTIFYING CHARACTERISTICS SPECIALTY CARE
CLUSTER A: ODD/ECCENTRIC Diagnosis or ongoing care of severe/chronic mental disorders, including bipolar
disorder, psychotic disorders such as schizophrenia, and psychotic symptoms in
Schizoid personality disorder Detachment from social relationships, restricted other disorders
emotional expression Management of more severe forms of other mental disorders and those refractory to
Schizotypal personality disorder Discomfort with close relationships, cognitive or treatment, including depression, anxiety disorders, and substance use disorders
perceptual distortions, eccentric behavior Need for safety evaluation or management, including suicidality, homicidality or
Paranoid personality disorder Pervasive distrust and suspiciousness of others’ other aggressivity, or inability to care for self
motives as malevolent Evaluation of decision-making capacity
CLUSTER B: DRAMATIC/EMOTIONAL/ERRATIC Diagnostic uncertainty
Borderline personality disorder Instability of interpersonal relationships, Psychiatric comorbid conditions complicating diagnosis or treatment, including
self-image, and affects, and marked personality and substance use disorders coexisting with other psychiatric
impulsivity disorders
Narcissistic personality disorder Grandiosity, need for admiration, and lack of Psychiatric-medical comorbid conditions complicating diagnosis or treatment,
empathy including management of psychiatric disorders during pregnancy
Antisocial personality disorder Pervasive disregard for and violation of the rights Need for expertise in psychopharmacologic treatment
of others, lack of true remorse (“conscience”) Need for expertise in other somatic therapies (e.g., electroconvulsive therapy, light
Histrionic personality disorder Pervasive excessive emotionality (theatricality) therapy)
and attention seeking Need for expertise in psychotherapy or other psychosocial interventions
CLUSTER C: ANXIOUS/FEARFUL
Avoidant personality disorder Social inhibition, feelings of inadequacy, and
sensitivity to negative views from others findings, including any previous history and immediate needs, and the clini-
Dependent personality disorder Pervasive and excessive need to be taken care of, cian’s own experience and expertise in assessing and managing the disorder
resulting in submissive and clinging behavior (Table 369-16).
and fears of separation
Obsessive-compulsive personality Pervasive preoccupation with orderliness,
disorder perfectionism, and mental and interpersonal
control Grade A References
Author summary based on criteria from American Psychiatric Association. Diagnostic and Statistical
Manual of Mental Disorders. 5th ed. (DSM-5) Washington, DC: American Psychiatric Association; A1. Qaseem A, Barry MJ, Kansagara D. Nonpharmacologic versus pharmacologic treatment of adult
2013. patients with major depressive disorder: a clinical practice guideline from the American College
of Physicians. Ann Intern Med. 2016;164:350-359.
A2. Gartlehner G, Gaynes BN, Amick HR, et al. Comparative benefits and harms of antidepressant,
psychological, complementary, and exercise treatments for major depression: an evidence report
for a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2016;
164:331-341.
A3. Cipriani A, Furukawa TA, Salanti G, et al. Comparative efficacy and acceptability of 21 antidepres-
sant drugs for the acute treatment of adults with major depressive disorder: a systematic review
TABLE 369-15 SOME IMPORTANT RISKS FOR SUICIDE AND and network meta-analysis. Lancet. 2018;391:1357-1366.
SUICIDE ATTEMPTS A4. Cuijpers P, Sijbrandij M, Koole SL, et al. Adding psychotherapy to antidepressant medication in
depression and anxiety disorders: a meta-analysis. World Psychiatry. 2014;13:56-67.
Mental disorder, particularly depressive, bipolar, substance use, psychotic, and A5. Amick HR, Gartlehner G, Gaynes BN, et al. Comparative benefits and harms of second generation
personality disorders antidepressants and cognitive behavioral therapies in initial treatment of major depressive disorder:
Other symptoms of acute psychic distress, particularly hopelessness and panic systematic review and meta-analysis. BMJ. 2015;351:1-10.
attacks A6. Wilkinson ST, Ballard ED, Bloch MH, et al. The effect of a single dose of intravenous ketamine on
Previous history of suicide attempt suicidal ideation: a systematic review and individual participant data meta-analysis. Am J Psychiatry.
Family history of suicide or suicide attempt (and, to a lesser degree, of any mental 2018;175:150-158.
disorder) A7. Richards DA, Ekers D, McMillan D, et al. Cost and outcome of behavioural activation versus cogni-
tive behavioural therapy for depression (COBRA): a randomised, controlled, non-inferiority trial.
Family violence, including physical or sexual abuse Lancet. 2016;388:871-880.
Access to firearms or other lethal methods A8. Grochtdreis T, Brettschneider C, Wegener A, et al. Cost-effectiveness of collaborative care for the
Incarceration treatment of depressive disorders in primary care: a systematic review. PLoS ONE. 2015;10:1-19.
Exposure to suicidal behavior of others (family, peers, public figures) A9. McGirr A, Vöhringer PA, Ghaemi SN, et al. Safety and efficacy of adjunctive second-generation
Social isolation antidepressant therapy with a mood stabiliser or an atypical antipsychotic in acute bipolar depres-
Interpersonal discord or other psychosocial stressors sion: a systematic review and meta-analysis of randomised placebo-controlled trials. Lancet Psychiatry.
Demographic factors, including male, non-Hispanic white or American Indian/ 2016;3:1138-1146.
Alaska Native race, older age A10. Chiang KJ, Tsai JC, Liu D, et al. Efficacy of cognitive-behavioral therapy in patients with bipolar
disorder: a meta-analysis of randomized controlled trials. PLoS ONE. 2017;12:1-19.
A11. Cuijpers P, Sijbrandij M, Koole S, et al. Psychological treatment of generalized anxiety disorder: a
meta-analysis. Clin Psychol Rev. 2014;34:130-140.
A12. Slee A, Nazareth I, Bondaronek P, et al. Pharmacological treatments for generalised anxiety disorder:
a systematic review and network meta-analysis. Lancet. 2019;393:768-777.
behavior cannot be made with certainty. The linchpin of the clinical evaluation A13. Reiter K, Andersen SB, Carlsson J. Neurofeedback treatment and posttraumatic stress disorder:
effectiveness of neurofeedback on posttraumatic stress disorder and the optimal choice of protocol.
is a methodical assessment of risks for suicide (Table 369-15), together with J Nerv Ment Dis. 2016;204:69-77.
direct questioning of the patient regarding thoughts of death, dying, and suicide; A14. Feder A, Parides MK, Murrough JW, et al. Efficacy of intravenous ketamine for treatment of chronic
specific plans (in ideation or action) for suicide; and the details of any attempts. posttraumatic stress disorder: a randomized clinical trial. JAMA Psychiatry. 2014;71:681-688.
Although most persons who attempt suicide do not die, a previous history of A15. Leucht S, Cipriani A, Spineli L, et al. Comparative efficacy and tolerability of 15 antipsychotic
drugs in schizophrenia: a multiple-treatments meta-analysis. Lancet. 2013;382:951-962.
a suicide attempt is a powerful risk for subsequent death by suicide. Suicide A16. Tiihonen J, Mittendorfer-Rutz E, Majak M, et al. Real-world effectiveness of antipsychotic treat-
attempts and verbal threats should always be evaluated carefully and never ments in a nationwide cohort of 29823 patients with schizophrenia. JAMA Psychiatry. 2017;74:686-693.
dismissed as “gestures” or “attention-seeking” behavior. Patients at increased A17. Németh G, Laszlovszky I, Czobor P, et al. Cariprazine versus risperidone monotherapy for treatment
of predominant negative symptoms in patients with schizophrenia: a randomised, double-blind,
risk for suicide should be referred for psychiatric evaluation, with emergency controlled trial. Lancet. 2017;389:1103-1113.
referral if the risk is deemed to be imminent or increasing.
WHEN TO REFER A PATIENT FOR
GENERAL REFERENCES
PSYCHIATRIC EVALUATION
Clinical decisions to refer a patient for specialty psychiatric evaluation must For the General References and other additional features, please visit Expert Consult
be made on an individual basis by taking into account the patient’s clinical at https://expertconsult.inkling.com.

2315.e1
GENERAL REFERENCES 12. Moon W, Kim SN, Park S, et al. The cost-effectiveness of deep brain stimulation for patients with
treatment-resistant obsessive-compulsive disorder. Medicine (Baltimore). 2017;96:1-8.
1. Gandal MJ, Haney JR, Parikshak NN, et al. Shared molecular neuropathology across major psychiatric 13. Kim SJ, Roh D, Jung HH, et al. A study of novel bilateral thermal capsulotomy with focused ultra-
disorders parallels polygenic overlap. Science. 2018;359:693-697. sound for treatment-refractory obsessive-compulsive disorder: 2-year follow-up. J Psychiatry Neurosci.
2. Stewart DE. Vigod S. Postpartum depression. N Engl J Med. 2016;375:2177-2186. 2018;43:327-337.
3. Malhi GS, Mann JJ. Depression. Lancet. 2018;392:2299-2312. 14. Shalev A, Liberzon I, Marmar C. Post-traumatic stress disorder. N Engl J Med. 2017;376:
4. Park LT, Zarate CA Jr. Depression in the primary care setting. N Engl J Med. 2019;380:559-568. 2459-2469.
5. Scott J, Murray G, Henry C, et al. Activation in bipolar disorders: a systematic review. JAMA Psychiatry. 15. Addington D, Abidi S, Garcia-Ortega I, et al. Canadian guidelines for the assessment and diagnosis
2017;74:189-196. of patients with schizophrenia spectrum and other psychotic disorders. Can J Psychiatry. 2017;62:
6. Grande I, Berk M, Birmaher B, et al. Bipolar disorder. Lancet. 2016;387:1561-1572. 594-603.
7. Shine B, McKnight RF, Leaver L, et al. Long-term effects of lithium on renal, thyroid, and parathyroid 16. Lieberman JA, First MB. Psychotic disorders. N Engl J Med. 2018;379:270-280.
function: a retrospective analysis of laboratory data. Lancet. 2015;386:461-468. 17. Remington G, Addington D, Honer W, et al. Guidelines for the pharmacotherapy of schizophrenia
8. Craske MG, Stein MB. Anxiety. Lancet. 2016;388:3048-3059. in adults. Can J Psychiatry. 2017;62:604-616.
9. Stein MB, Sareen J. Clinical practice: generalized anxiety disorder. N Engl J Med. 2015;373: 18. Clark LA, Nuzum H, Ro E. Manifestations of personality impairment severity: comorbidity, course/
2059-2068. prognosis, psychosocial dysfunction, and ‘borderline’ personality features. Curr Opin Psychol.
10. Hirschtritt ME, Bloch MH, Mathews CA. Obsessive-compulsive disorder: advances in diagnosis 2017;21:117-121.
and treatment. JAMA. 2017;317:1358-1367. 19. Turecki G, Brent DA. Suicide and suicidal behaviour. Lancet. 2016;387:1227-1239.
11. Leichsenring F, Leweke F. Social anxiety disorder. N Engl J Med. 2017;376:2255-2264.
2315.e2 CHAPTER 369 Psychiatric Disorders in Medical Practice

REVIEW QUESTIONS Answer: E Please see text regarding bipolar II disorder under “Other Mood
Disorders.” Antidepressant therapy in this condition may precipitate hypomania
1. Which of the following types of disorders may manifest with a combina- (or mania). At the least, extremely careful monitoring is required, and many
tion of substantial intellectual deficits, mood symptoms, psychotic symptoms, experts recommend not starting antidepressant therapy at all until reevaluating
and anxiety symptoms? the patient after institution of treatment with a mood stabilizer such as lithium
A . Anxiety disorders or valproate.
B. Bipolar disorders
C. Depressive disorders 4. Which of the following disorders has a pathophysiology that is probably
D. Neurocognitive disorders mediated primarily by striatofrontal systems?
E. Psychotic disorders
A . Generalized anxiety disorder
Answer: D See Table 369-2. Although the hallmark of neurocognitive dis- B. Obsessive-compulsive disorder
orders is intellectual deficits, they often manifest with symptoms affecting C. Panic disorder
other parts of the mental status examination, including mood, psychotic, and D. Post-traumatic stress disorder
anxiety symptoms. Intellectual deficits consistent with delirium or dementia E. Social anxiety disorder
are not characteristic of anxiety, bipolar, depressive, or psychotic disorders.
Answer: B As discussed in the text under anxiety disorders and other disor-
ders with prominent anxiety, obsessive-compulsive disorder has been reclas-
2. After complete resolution of a first episode of major depression with anti- sified separate from the anxiety disorders because of its differing pathophysiology.
depressant medication therapy, how long should the medication be Post-traumatic stress disorder also has been classified separately (under trauma-
continued? and stress-related disorders), but its neurobiology appears to be more closely
A . Not at all; discontinue as soon as the episode has resolved related to the anxiety disorders than to obsessive-compulsive disorder.
B. 1 week
C. 1 month 5. Which of the following predicts better longer-term outcome in schizophrenia?
D. At least 6 to 12 months
E. Indefinitely for lifelong maintenance therapy A . Absence of negative symptoms such as apathy and social withdrawal
B. Enduring family discord
Answer: D As noted in the section on treatment of major depression, con- C. Being male
tinuation of treatment is required to prevent relapse into the depressive episode. D. Ongoing psychosocial stressors
The continuation phase should be at least 6 to 12 months. However, assuming E. Younger age of onset
the patient’s symptoms remain in full remission at the end of the continuation
phase, lifelong maintenance therapy is indicated only for patients with recur- Answer: A As discussed in the section on schizophrenia, each of factors B
rent episodes of depression (and, some believe, for others at particularly high through E predicts a poorer outcome. Prominent negative symptoms predict
risk for recurrence or for the destructive effects of another depressive episode, a poorer course, as reflected in the poor response of negative symptoms to
e.g., late-onset depression, highly suicidal depression). antipsychotic medications (hence the need for psychosocial rehabilitation
programs in this condition). The absence of negative symptoms suggests higher
functioning if the positive (psychotic) symptoms of the disorder can be con-
3. For patients who present with a major depressive episode, it is important trolled with medication.
to inquire about any prior history of hypomania, because such a history
has which of the following implications for treatment?
A . Need to treat all first-degree relatives prophylactically
B. Need to obtain informed consent from the nearest relative
C. More likely to respond to antidepressant medication
D. More likely to respond to psychotherapy
E. May require mood stabilizer treatment before antidepressant therapy

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CHAPTER 369 Psychiatric Disorders in Medical Practice

Psychiatric disorders are defined as disorders of the psyche—that is, condi-

OVERVIEW Comorbid Conditions in Psychiatry

TABLE 369-2 IMPORTANT PSYCHIATRIC SYNDROMES AND DISORDERS

The symptoms of depression (see Table 369-3) may be conceptually grouped

TABLE 369-5 COMMONLY USED ANTIDEPRESSANT MEDICATIONS*

to see patients regularly (every 1 to 2 weeks initially) to monitor their clinical

Optimal guideline-based treatment of major depression results in full remis-

OTHER MOOD DISORDERS PATHOBIOLOGY

ANXIETY DISORDERS CLINICAL MANIFESTATIONS

EPIDEMIOLOGY Panic Disorder

TABLE 369-8 COMMON SOMATIC MANIFESTATIONS OF

TABLE 369-9 SELECTED ANTIANXIETY AND HYPNOTIC DRUGS*

During the course of illness, at least one episode of schizophrenia-like psychotic

TABLE 369-12 COMMONLY USED ANTIPSYCHOTIC MEDICATIONS

Schizoaffective Disorder TREATMENT

TABLE 369-13 SOMATIC SYMPTOM AND RELATED TREATMENT

TABLE 369-14 PERSONALITY DISORDERS TABLE 369-16 GENERAL CONSIDERATIONS IN DECIDING TO

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