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They have a much lower incidence of extrapyramidal side effects. If the medication fails, it is appropriate to switch to another medication in a different class. Patients are helped through a variety of methods to improve their social skills, become self-sufficient, and act appropriately in public.

Family therapy and group therapy are also useful adjuncts. Benzodiazepines, beta blockers, and cholinomimetics may be used short term. The movements often persist despite withdrawal of the offending drug. Tardive dyskinesia occurs 5. Weight gain, sedation, orthostatic hypotension, electrocardiogram most often in older women changes, hyperprolactinemia leading to gynecomastia, galactorrhea, after at least 6 months of amenorrhea, diminished libido, and impotence , hematologic effects medication.

The only difference between the two is that in schiz- ophreniform disorder the symptoms have lasted between 1 and 6 months, Neuroleptic malignant whereas in schizophrenia the symptoms must be present for more than 6 syndrome is most common months. In Psychotic Disorders symptoms last from 1 day to 1 month. Symptoms must not be due to general the past winter, he never medical condition or drugs. This is a rare diagnosis, much less common than went outside for this reason schizophrenia.

Antipsychotic medications are often ineffec- tive, but a course of them should be tried usually a high-potency traditional antipsychotic or one of the newer atypical antipsychotics is used. TABLE Schizophrenia vs. Most people suffering from shared psychotic disorder complain about him to the are family members. The first step is to separate the patient from the person who is the source of shared delusions usually a family member with an underlying psychotic disor- Think: Delusional disorder.

Amok Sudden unprovoked outbursts of violence of Malaysia, which the person has no recollection. Southeast Asia Psychotic Disorders Person often commits suicide afterwards. Think: Shared eccentric, lack of friends, social anxiety. Criteria for true psychosis are psychotic disorder. Both external and internal stimuli can trigger moods, which may be labeled as sad, happy, angry, irritable, and so on.

Patients with mood disorders experience an abnormal range of moods and lose some level of control over them. Distress may be caused by the severity of their moods and their resulting impairment in social and occupational func- tioning. Mood disorders have also been called affective disorders. Mood Disorders Versus Mood Episodes Mood episodes are distinct periods of time in which some abnormal mood is present. Mood disorders are defined by their patterns of mood episodes.

Depressed mood Guilt 2. Anhedonia loss of interest in pleasurable activities 3. Change in appetite or body weight increased or decreased Energy 4. Feelings of worthlessness or excessive guilt Concentration 5. Insomnia or hypersomnia Appetite 6. Diminished concentration 7. Psychomotor agitation or retardation i. Fatigue or loss of energy Suicidal ideation 9. A period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week and including at least three of the following four if mood is irritable : 1.

Distractibility 2. Inflated self-esteem or grandiosity Mood Disorders Symptoms of mania: 3. Decreased need for sleep Distractability 5. Flight of ideas or racing thoughts Insomnia 6.

More talkative or pressured speech rapid and uninterruptible Grandiosity 7. Excessive involvement in pleasurable activities that have a high risk of negative consequences e. Seventy-five percent of Thoughtlessness manic patients have psychotic symptoms. Mixed Episode Criteria are met for both manic episode and major depressive episode. These criteria must be present nearly every day for at least 1 week.

As with a manic episode, this is a psychiatric emergency. Irritability is usually the predominant mood state in mixed episodes.

Patients Hypomanic Episode with mixed episodes have a A hypomanic episode is a distinct period of elevated, expansive, or irritable poorer response to lithium. There are significant differences between mania and hypomania see below. Always investigate medical or substance-induced causes see below be- fore making a diagnosis. Patients may be unaware of their depressed mood or may been put into a geriatric express vague, somatic complaints. Patients re- attending her Thursday spond to treatment with light therapy.

Decreased brain and cerebrospinal fluid CSF levels of serotonin and its main metabolite, 5-hydroxyindolacetic acid 5-HIAA , are found in depressed patients. Abnormal regulation of beta-adrenergic recep- tors has also been shown. Drugs that increase availability of serotonin, norepinephrine, and dopamine often alleviate symptoms of depression. Other Neuroendocrine Abnormalities 1. High cortisol: Hyperactivity of hypothalamic—pituitary—adrenal axis as shown by failure to suppress cortisol levels in dexamethasone sup- pression test.

Abnormal thyroid axis: Thyroid disorders are associated with depres- sive symptoms, and one third of patients with MDD who have other- wise normal thyroid hormone levels show blunted response of thyroid- stimulating hormone TSH to infusion of thyrotropin-releasing hormone TRH.

Many other neurotransmitters and hormonal factors have also shown poten- tial involvement in the pathophysiology of mood disorders, including gamma- aminobutyric acid GABA and endogenous opiates.

Stable family and social functioning have been shown to be MDD may have psychotic good prognostic indicators in the course of major depression. Generally, episodes occur more frequently as the disorder progresses. Antidepressant medications significantly reduce the length and severity of symptoms. They may be used prophylactically between major depressive episodes to reduce the risk of subsequent episodes.

Medications include sedation, weight gain, orthostatic hypotension, and anticholin- usually take 4 to 8 weeks ergic effects. Can aggravate prolonged QTC syndrome. Most common side effect is orthosta- tic hypotension. Tyramine is an intermediate in the conversion of ty- Serotonin syndrome is rosine to norepinephrine. Coma or such as the terminally ill or patients with refractory symptoms. Though death may result.

Characterized by anhedonia, early morning awakenings, psychomotor dis- turbance, excessive guilt, and anorexia. May also be applied to bipolar disorder. Characterized by the presence of delusions or hallucinations. It is tradi- tionally known as manic depression. Be- your differential of a tween manic episodes, there may be interspersed euthymia, major depressive episodes, dysthymia, or hypomanic episodes, but none of these are required for psychotic patient.

Over First-degree relatives of patients with bipolar disorder are 8 to 18 times more the past 2 weeks, he comes likely to develop the illness. Concordance rates for monozygotic twins are ap- home at 3 A.

The course is usually Gates. Think: Bipolar disorder. Lithium prophylaxis between episodes helps to decrease the risk of relapse. They rarely need hospitalization. Depressed mood for the majority of time of most days for at least 2 years in children for at least 1 year 2. Double depression: Patients with major depressive disorder with dysthymic disorder during residual periods Dysthymia can never have psychotic features. Think: Cyclothymia. Autonomic symptoms of anxiety include palpitations, perspiration, dizziness, mydriasis, gastrointestinal disturbances, and urinary urgency and frequency.

There is often a shortness of breath or choking sensation. Anxiety is a common, normal response to a perceived threat. It is important for clinicians to be able to distinguish normal from pathological anxiety.

When anxiety is pathological, it is inappropriate; there is either no real source of fear or the source is not sufficient to account for the severity of the symp- toms. In people with anxiety disorders, the symptoms interfere with daily functioning and interpersonal relationships. They are associated with neurotransmitter imbalances, including increased activity of norepinephrine and decreased ac- tivity of gamma-aminobutyric acid GABA and serotonin. Anxiety disorders develop more frequently in higher socioeconomic groups.

Panic attacks often peak in several minutes and subside within 25 minutes. Attacks may be either unexpected or provoked by specific triggers. They may be described as a sudden rush of fear. Spontaneous recurrent panic attacks see above with no obvious pre- cipitant 2. In addition to physical symptoms such as tachycardia, sweating, and shortness of breath , the patient experiences ex- shows no abnormalities.

Attacks occur an average of two times per week but may range from several times per day to a few times per year. They usually last be- tween 20 and 30 minutes, and anticipatory anxiety about having another attack is common between episodes. Research has revealed dysregulation of the autonomic nervous complaining of a pounding system, central nervous system, and cerebral blood flow in patients with panic heart, shortness of breath, disorder.

Increased activity of norepinephrine and decreased activity of sero- and sweating that began tonin and GABA have also been shown in these patients. She expresses that she thought Certain substances have been shown to induce panic attacks in patients with she was going to die. Think: Panic disorder. Social and specific phobias 4. It is important to rule out these conditions before making the diagnosis of panic disorder.

Always start SSRIs at low TREATMENT dose and increase slowly in panic disorder patients, as Pharmacological they are prone to develop Acute Initial Treatment of Anxiety activation side effects from Benzodiazepines only short course if necessary, as dependence may occur these medications anxiety with long-term use ; Dose should be tapered as treatment with selective sero- symptoms that mimic those tonin reuptake inhibitors SSRIs is instituted.

Maintenance SSRIs, especially paroxetine and sertraline, are the drugs of choice for long- term treatment of panic disorder. These drugs typically take 2 to 4 weeks to become effective, and higher doses are required than for depression. Clomipramine, imipramine, or other antidepressants may also be used. Treat- ment should continue for at least 8 to 12 months, as relapse is common after discontinuation of therapy.

It often develops sec- ondary to panic attacks due to apprehension about having subsequent attacks in public places where escape may be difficult. She states that these symptoms also occur when Clinical progression: A person who has a panic attack while shopping in a she is in crowded waiting large supermarket subsequently develops a fear of entering that supermarket. She has decided to As the person experiences more panic attacks in different settings, he or she develops a progressive and more general fear of public spaces agoraphobia.

Think: Panic disorder with agorophobia. Since agoraphobia is usually associated with panic disorder, SSRIs are also considered first-line treatment.

Behavioral therapy may also be indicated. As coexisting panic disorder is treated, agoraphobia usually resolves. When ago- raphobia is not associated with panic disorder, it is usually chronic and debili- tating.

Specific and Social Phobias A phobia is defined as an irrational fear that leads to avoidance of the feared object or situation. A specific phobia is a strong, exaggerated fear of a specific object or situation; a social phobia also called social anxiety disorder is a fear of social situations in which embarrassment can occur. Exposure to the situation brings about an immediate anxiety response. Patient recognizes that the fear is excessive. The situation is avoided when possible or tolerated with intense anxi- Common Social Phobias ety.

If person is under age 18, duration must be at least 6 months. He Phobias are the most common mental disorders in the United States. The diagnosis of specific pho- a project on the 50th floor bia is more common than social phobia. Onset can be as early as 5 years old and has had trouble doing for phobias such as seeing blood, and as old as 35 for situational fears such as a fear of heights.

The average age of onset for social phobias is mid-teens. Think: Specific phobia. Women are two times as likely to have specific phobia as men; social phobia occurs equally in men and women. First-degree rel- especially alcohol-related atives of patients with social phobia are three times more likely to de- disorders. Up to one third velop the disorder. For example, people who were in a car accident may develop a specific phobia for driving.

This has led to the successful treat- ment of some phobias. Most notably, performance anxiety is often suc- Anxiety and Adjustment cessfully treated with beta blockers. Last Monday, she Specific Phobia stayed home although she Pharmacological treatment has not been found effective. Systemic desensiti- had to give a speech in zation with or without hypnosis and supportive psychotherapy are often use- class, because she did not ful.

Think: Social Systemic desensitization: Gradually expose patient to feared object or situa- phobia. Beta blockers are frequently used to control symptoms of perfor- mance anxiety. Cognitive and behavioral therapies are useful adjuncts.

They usually relieve this anxiety A year-old medical with recurrent standardized behaviors compulsions. Patients are generally student comes to your office aware of their problems and realize that their thoughts and behaviors are irra- because he is distressed by tional they have insight.

The symptoms cause significant distress in their his repetitive checking of lives, and patients wish they could get rid of them i.

He states that after he parks the car and gets to OCD can cause significant impairment of daily functioning, as behaviors are his house, he feels as if the often time consuming and interfere with routines, work, and interpersonal re- car door is not locked and lationships.

Think: Obsessive— marked anxiety and are not simply excessive worries about real prob- compulsive disorder. The person is aware that the obsessions and compulsions are unreason- able and excessive. The obsessions cause marked distress, are time consuming, or signifi- compulsions. Obsessions about contamination followed by excessive washing or compulsive avoidance of the feared contaminant 2.

Obsessions of doubt forgetting to turn off the stove, lock the door, etc. Obsessions about symmetry followed by compulsively slow perfor- Personality Disorder: mance of a task such as eating, showering, etc.

Intrusive thoughts with no compulsion. Thoughts are often sexual or OCD! This is a personality violent. He or she is fected as women. The technique, called exposure and response prevention ERP , in- hand washing. Relaxation techniques are employed to help the patient manage the anxiety that occurs when the compulsion is prevented. Posttraumatic Stress Disorder PTSD PTSD is a response to a catastrophic life-threatening life experience in which the patient reexperiences the trauma, avoids reminders of the event, and experiences emotional numbing or hyperarousal.

The event was potentially harmful or fatal, and the initial reaction was intense fear or horror. Example: A woman will not enter parking lots after being raped in one. The presence of To qualify for this diagnosis, the symptoms must occur within 1 month of the psychological symptoms Anxiety and Adjustment trauma and last for a maximum of 1 month. Symptoms are similar to those of after a stressful but PTSD. Same as treatment for PTSD see above.

Patients with GAD have persistent, excessive anxiety and hyperarousal for at least 6 months. They worry about general daily events, and their anxiety is difficult to control. Most seek out a specialist wonders if she is capable of because of their somatic complaints that accompany this disorder, such as doing her job and feels as if muscle tension or fatigue.

Think: cially major depression, social or specific phobia, or panic disorder. Anxiety and Adjustment Generalized anxiety disorder. The other half of patients will fully recover within several years of therapy. They occur when maladaptive behavioral or emotional symptoms develop after a stressful life event. Symptoms begin within 3 months after the event, end within 6 It is important to rule out months, and cause significant impairment in daily functioning or interper- medical conditions that sonal relationships.

Development of emotional or behavioral symptoms within 3 months after a stressful life event. The symptoms are not those of bereavement. Symptoms resolve within 6 months after stressor has terminated. In PTSD, it is. Many people have odd Personality disorders involve deeply ingrained, inflexible patterns of relating to tendencies and quirks; others that are maladaptive and cause significant impairment in social or oc- these are not pathological cupational functioning.

Patients with personality disorders lack insight about unless they cause their problems; their symptoms are ego-syntonic. Personality disorders are significant distress or Axis II diagnoses. Many patients with personality disorders will meet the criteria for more than one disorder. They should be classified as having all of the disorders for which they qualify. The prevalence of personality disorders in monozygotic twins is several times higher than in dizygotic twins.

The disorders tend to be chronic and lifelong. In general, pharmacologic treatment has limited usefulness see indi- vidual exceptions below except in treating coexisting symptoms of depres- sion, anxiety, and the like. Psychotherapy and group therapy are usually the most helpful. They tend to blame their own prob- A year-old male says lems on others and seem angry and hostile. At least four of the following must also be her needs. He also claims present: that on his previous job, his 1.

Suspicion without evidence that others are exploiting or deceiving boss laid him off because him or her he did a better job than his 2. Preoccupation with doubts of loyalty or trustworthiness of acquain- boss. Think: Paranoid tances personality disorder. Reluctance to confide in others 4. Interpretation of benign remarks as threatening or demeaning 5.

Persistence of grudges 6. Perception of attacks on his or her character that are not apparent to others; quick to counterattack 7. Patients may also benefit from an- tianxiety medications or short course of antipsychotics for transient psychosis. Schizoid Personality Disorder Patients with schizoid personality disorder have a lifelong pattern of social Unlike with avoidant withdrawal.

They are often perceived as eccentric and reclusive. They are personality disorder, quiet and unsociable and have a constricted affect. They have no desire for patients with schizoid close relationships and prefer to be alone. Four or more of the following must also be present: 1. Neither enjoying nor desiring close relationships including family 2.

Generally choosing solitary activities A year-old scientist 3. Little if any interest in sexual activity with another person works in the lab most of 4. Taking pleasure in few activities if any the day and has no friends, 5.

Few close friends or confidants if any according to his coworkers. Indifference to praise or criticism He expresses no desire to 7. Emotional coldness, detachment, or flattened affect make friends and is content with his single life. They are often perceived as strange and eccentric. Five or more of the following in a space suit every must be present: Tuesday and Thursday.

He has computers set up in his 1. Ideas of reference excluding delusions of reference 2. Unusual perceptual experiences such as bodily illusions precise time of alien Personality Disorders 4. Suspiciousness invasion. Inappropriate or restricted affect evidence of auditory or 6. Odd or eccentric appearance or behavior visual hallucinations. Think: 7. Few close friends or confidants Schizotypal personality 8.

Odd thinking or speech vague, stereotyped, etc. These patients are often emotional, impulsive, and dramatic. They are impulsive, deceitful, and often violate the law. However, they often appear charming and normal Antisocial personality to others who meet them for the first time and do not know their history. Three or more of the following or starting fires.

It is often should be present: associated with violations of Personality Disorders the law. Failure to conform to social norms by committing unlawful acts 2. Recklessness and disregard for safety of self or others 6. Patients who began other kids. Think: Antisocial abusing drugs before their antisocial behavior started may have behavior at- personality disorder. Pharmacotherapy may be used to treat symptoms of anxiety or depression, but use caution due to high addictive Borderline personality: potential of these patients.

They feel alone in the world and have problems with self-image. Desperate efforts to avoid real or imagined abandonment 2. Unstable, intense interpersonal relationships 3. Unstable self-image The name borderline comes 4.

Recurrent suicidal threats or attempts or self-mutilation and psychosis. General feeling of emptiness 8. Difficulty controlling anger 9. Usually has a stable, chronic course. Every tionality. They are dramatic, flamboyant, and extroverted but are unable to doctor I met before you was horrible. They are often sexually inappro- priate and provocative. At least five of the following must be shown to be more useful in present: borderline personality disorder than in any other 1.

Uncomfortable when not the center of attention personality disorder. Inappropriately seductive or provocative behavior 3. Uses physical appearance to draw attention to self 4. Has speech that is impressionistic and lacking in detail 5.

Theatrical and exaggerated expression of emotion 6. Easily influenced by others or situation 7. HPD patients are generally more functional. Patients with NPD have a sense of superiority, a need for admiration, and a lack of empathy.

Despite their grandiosity, however, these patients often have fragile self-esteems. He early adulthood and present in a variety of contexts. Five or more of the fol- lowing must be present: does not let the residents operate on him and 1. Exaggerated sense of self-importance requests the Chief of 2. Now you can get real answers to real board questions! Features: Hundreds of high-yield facts, mnemonics, clinical images, and summary tables help you ace the boards and in-service exams Covers must-know psychiatry and neurology topics in one complete volume Written by recent, successful test-takers and reviewed by top faculty so you know you're studying the most relevant, up-to-date material possible Integrated mini-cases review frequently tested scenarios and classic patient presentations Great for in-service and board exams and the perfect refresher before recertification Insider Coverage of All the Must-Know Topics: Guide to the ABPN Examination, Psychiatry Topics Disorders of Childhood Onset, Unipolar Depressive Disorders, Bipolar Disorder, Primary Psychotic Disorders, Substance Abuse and Dependence, Anxiety Disorders, Personality Disorders, Eating Disorders, Somatoform Disorders, Sleep and Sleep Disorders, D.

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