Current Clinical

Strategies

Psychiatry
2008 Edition

Rhoda K Hahn, MD

Lawrence J. Albers, MD
Associate Clinical Professor
Department of Psychiatry and Human Behavior
University of California, Irvine, College of Medicine

Christopher Reist, MD
Professor and Vice Chairman
Department of Psychiatry and Human Behavior
University of California, Irvine, College of Medicine

Current Clinical Strategies

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Assessment and
Evaluation

Clinical Evaluation of the

Psychiatric Patient
I. Psychiatric History
A. Identifying information. Age, sex, marital status,
race, referral source.
B. Chief complaint (CC). Reason for consultation;
the reason is usually a direct quote from the
patient.
C. History of present illness (HPI)
1. Current symptoms: date of onset, duration
and course of symptoms.
2. Previous psychiatric symptoms and treatment.
3. Recent psychosocial stressors: stressful life
events that may have contributed to the
patient's current presentation.
4. Reason the patient is presenting now.
5. This section provides evidence that supports or
rules out relevant diagnoses. Therefore,
documenting the absence of pertinent
symptoms is also important.
6. Historical evidence in this section should be
relevant to the current presentation.
D. Past psychiatric history
1. Previous and current psychiatric diagnoses.
2. History of psychiatric treatment, including
outpatient and inpatient treatment.
3. History of psychotropic medication use.
4. History of suicide attempts and potential
lethality.
E. Past medical history
1. Current and/or previous medical problems.
2. Type of treatment, including prescription, over-
the-counter medications, home remedies.
 F. Family history. Relatives with history of
psychiatric disorders, suicide or suicide attempts,
alcohol or substance abuse.
G. Social history
1. Source of income.
2. Level of education, relationship history
(including marriages, sexual orientation,
number of children); individuals who currently
live with patient.
3. Support network.
4. Current alcohol or illicit-drug usage.
5. Occupational history.
H. Developmental history. Family structure during
childhood, relationships with parental figures and
siblings; developmental milestones, peer
relationships, school performance.
II. Mental Status Exam. The mental status exam is an
assessment of the patient at the present time.
Historical information should not be included in this
section.
A. General appearance and behavior
1. Grooming, level of hygiene, characteristics of
clothing.
2. Unusual physical characteristics or movements.
3. Attitude. Ability to interact with the interviewer.
4. Psychomotor activity. Agitation or retardation.
5. Degree of eye contact.
B. Affect
1. Definition. External range of expression,
described in terms of quality, range and
appropriateness.
2. Types of affect
a. Flat. Absence of all or most affect.
b. Blunted or restricted. Moderately reduced
range of affect.
c. Labile. Multiple abrupt changes in affect.
d. Full or wide range of affect. Generally
appropriate.
C. Mood. Internal emotional tone of the patient (ie,
dysphoric, euphoric, angry, euthymic, anxious).
D. Thought processes
1. Use of language. Quality and quantity of
speech. The tone, associations and fluency of
speech should be noted.
2. Common thought disorders
a. Pressured speech. Rapid speech, which is
typical of patients with manic disorder.
b. Poverty of speech. Minimal responses,
such as answering just “yes or no.”
c. Blocking. Sudden cessation of speech,
often in the middle of a statement.
d. Flight of ideas. Accelerated thoughts that
jump from idea to idea, typical of mania.
e. Loosening of associations. Illogical
shifting between unrelated topics.
f. Tangentiality. Thought that wanders from
the original point.
g. Circumstantiality. Unnecessary digression,
which eventually reaches the point.
h. Echolalia. Echoing of words and phrases.
i. Neologisms. Invention of new words by the
patient.
j. Clanging. Speech based on sound, such as
rhyming and punning rather than logical
connections.
k. Perseveration. Repetition of phrases or
words in the flow of speech.
l. Ideas of reference. Interpreting unrelated
events as having direct reference to the
patient, such as believing that the television
is talking specifically to them.
E. Thought content
1. Definition. Hallucinations, delusions and other
perceptual disturbances.
2. Common thought content disorders
a. Hallucinations. False sensory perceptions,
which may be auditory, visual, tactile,
gustatory or olfactory.
b. Delusions. Fixed, false beliefs, firmly held in
spite of contradictory evidence.
i. Persecutory delusions. False belief
that others are trying to cause harm, or
are spying with intent to cause harm.
ii. Erotomanic delusions. False belief that
a person, usually of higher status, is in
love with the patient.
iii. Grandiose delusions. False belief of an
inflated sense of self-worth, power,
knowledge, or wealth.
iv. Somatic delusions. False belief that the
patient has a physical disorder or defect.
c. Illusions. Misinterpretations of reality.
d. Derealization. Feelings of unrealness
involving the outer environment.
 e. Depersonalization. Feelings of unrealness,
such as if one is “outside” of the body and
observing his own activities.
f. Suicidal and homicidal ideation. Suicidal
and homicidal ideation requires further
elaboration with comments about intent and
planning (including means to carry out plan).
F. Cognitive evaluation
1. Level of consciousness.
2. Orientation: Person, place and date.
3. Attention and concentration: Repeat five
digits forwards and backwards or spell a five-
letter word (“world”) forwards and backwards.
4. Short-term memory: Ability to recall three
objects after five minutes.
5. Fund of knowledge: Ability to name past five
presidents, five large cities, or historical dates.
6. Calculations. Subtraction of serial 7s, simple
math problems.
7. Abstraction. Proverb interpretation and
similarities.
G. Insight. Ability of the patient to display an
understanding of his current problems, and the
ability to understand the implication of these
problems.
H. Judgment. Ability to make sound decisions
regarding everyday activities. Judgement is best
evaluated by assessing a patient's history of
decision making, rather than by asking
hypothetical questions.
III. DSM-IV Multiaxial Assessment Diagnosis
Axis I: Clinical disorders.
Other conditions that may be a focus of
clinical attention.
Axis II: Personality disorders.
Mental retardation.
Axis III: General medical conditions.
Axis IV: Psychosocial and environmental problems.
Axis V: Global assessment of functioning.
IV. Treatment plan. This section should discuss
pharmacologic treatment and other psychiatric
therapy, including hospitalization.
V. General medical screening of the psychiatric
patient. A thorough physical and neurological
examination, including basic screening laboratory
studies to rule out physical conditions, should be
completed.
A. Laboratory evaluation of the psychiatric
patient
1. CBC with differential.
2. Blood chemistry (SMAC).
3. Thyroid function panel.
4. Screening test for syphilis (RPR or MHA-TP).
5. Urinalysis with drug screen.
6. Urine pregnancy check for females of
childbearing potential.
7. Blood alcohol level.
8. Serum levels of medications.
9. Hepatitis C testing in at-risk patients.
10. HIV test in high-risk patients.
B. A more extensive work-up and laboratory studies
may be indicated based on clinical findings.

Admitting Orders
Admit to: (Name of unit).
Diagnosis: DSM-IV diagnosis justifying the admit.

Legal Status: Voluntary or involuntary status- if

involuntary, state specific status.
Condition: Stable.
Allergies: No known allergies.
Vitals: Standard orders are q shift x 3, then q day if
stable; if there are medical concerns, vitals should be
ordered more frequently.
Activity: Restrict to the unit or allow patient to leave unit.
Precautions: Assault or suicide precautions, elopement
precautions.
Diet: Regular diet, ADA diet, soft mechanical.
Labs: Chem 20, CBC with diff, UA with toxicology
screen, urine pregnancy test, RPR, thyroid function,
serum levels of medications.
Medications: As indicated by the patient’s diagnosis or
target symptoms. Include as-needed medications,
such as Tylenol, milk of magnesia, antacids.

Schizophrenia Admitting Orders

Admit to: Acute Psychiatric Unit.
Diagnosis: Schizophrenia, Continuous Paranoid Type,
Acute Exacerbation.
Legal Status: Involuntary by conservator.
Condition: Actively Psychotic.
Allergies: No known allergies.
Vitals: q shift x 3, then q day if stable.
Activity: Restrict to unit.
Precautions: Assault precautions.
Diet: Regular.
Labs: Chem 20, CBC with diff, UA with toxicology
screen, urine pregnancy test, RPR, thyroid function.
Medications:
Risperidone (Risperdal) 2 mg po bid x 2 days, then 4
mg po qhs.
Lorazepam (Ativan) 2 mg po q 4 hours prn agitation
(not to exceed 8 mg/24 hours.
Zolpidem (Ambien) 10 mg po qhs prn insomnia.
Tylenol 650 mg po q 4 hours prn pain or fever.
Milk of magnesia 30 cc po q 12 hours prn constipation.
Mylanta 30 cc po q 4 hours prn dyspepsia.

Bipolar I Disorder Admitting Orders

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

Major Depression Admitting Orders

Admit to: Acute Psychiatric Unit.
Diagnosis: Major Depression, severe, without psychotic
features.
Legal Status: Voluntary.
Condition: Stable.
Allergies: No known allergies.
Vitals: q shift x 3, then q day if stable.
Activity: Restrict to unit.
Precautions: Suicide precautions.
Diet: Regular.
Labs: Chem 20, CBC with diff, UA with toxicology
screen, urine pregnancy test, RPR, thyroid function.
Medications:
Sertraline (Zoloft) 50 mg po qAM.
Lorazepam (Ativan) 2 mg po q 4 hours prn agitation
(not to exceed 8 mg/24 hours.
Trazodone (Desyrel) 50 mg po qhs prn insomnia.
Tylenol 650 mg po q 4 hours prn pain or fever.
Milk of magnesia 30 cc po q 12 hours prn constipation.
Mylanta 30 cc po q 4 hours prn dyspepsia.

Alcohol Dependence Admitting

Orders
Admit to: Alcohol Treatment Unit.
Diagnosis: Alcohol Dependence.
Legal Status: Voluntary.
Condition: Guarded.
Allergies: No known allergies.
Vitals: q shift x 3 days, then q day if stable.
Activity: Restrict to unit.
Precautions: Seizure and withdrawal precautions.
Diet: Regular with one can of Ensure with each meal.
Labs: Chem 20, CBC with diff, UA with toxicology
screen, urine pregnancy test, RPR, thyroid function.
Medications:
Folate 1 mg po qd.
Thiamine 100 mg IM qd x 3 days, then 100 mg po qd.
Multivitamin 1 po qd.
Lorazepam (Ativan) 2 mg po tid x 2 days, then 2 mg
bid x 2 days, then 1 mg po bid x 2 days, then
discontinue.
Lorazepam (Ativan) 2 mg po q 4 hours prn alcohol
withdrawal symptoms (pulse >100, systolic BP
 >160, diastolic BP >100 [not to exceed 14 mg/24
hour]).
Zolpidem (Ambien) 10 mg po qhs prn insomnia.
Tylenol 650 mg po q 4 hours prn pain or fever.
Milk of magnesia 30 cc po q 12 hours prn constipation.
Mylanta 30 cc po q 4 hours prn dyspepsia.

Opiate Dependence Admitting

Orders
Admit to: Acute Psychiatric Unit.
Diagnosis: Heroin dependance.
Legal Status: Voluntary.
Condition: Stable.
Allergies: No known allergies.
Vitals: q shift x 3 days, then q day if stable.
Activity: Restrict to unit.
Precautions: Opiate withdrawal.
Diet: Regular.
Labs: Chem 20, CBC with diff, UA with toxicology
screen, urine pregnancy test, RPR, thyroid function,
hepatitis panel, HIV.
Medications:
Clonidine (Catapres) 0.1 mg po qid, hold for systolic
BP <90 or diastolic BP <60). Give 0.1 mg po q 4
hours prn signs and symptoms of opiate withdrawal.
Dicyclomine (Bentyl) 20 mg po q 6 hours prn
cramping.
Ibuprofen (Advil) 600 mg po q 6 hours prn
pain/headache.
Methocarbamol (Robaxin) 500 mg po q 6 hours prn
muscle pain.
Lorazepam (Ativan) 2 mg po q 4 hours prn agitation
(not to exceed 8 mg/24 hours.
Zolpidem (Ambien) 10 mg po qhs prn insomnia.
Milk of magnesia 30 cc po q 12 hours prn constipation.
Mylanta 30 cc po q 4 hours prn dyspepsia.

Schizoaffective Disorder Admitting

Orders
Admit to: Acute Psychiatric Unit.
Diagnosis: Schizoaffective disorder, bipolar type,
depressed.
Legal Status: Voluntary.
Condition: Stable.
Allergies: No known allergies.
Vitals: q shift x 3, then q day if stable.
Activity: Restrict to unit.
Precautions: Suicide precautions.
Diet: Regular.
Labs: Chem 20, CBC with diff, UA with toxicology
screen, urine pregnancy test, RPR, thyroid function,
lithium level.
Medications:
Quetiapine (Seroquel) 100 mg po bid x 2 days, then
200 mg po bid.
Lithium 600 mg po bid.
Citalopram (Celexa) 20 mg po q am.
Lorazepam (Ativan) 2 mg po q 4 hours prn agitation
(not to exceed 8 mg/24 hours).
Zolpidem (Ambien) 10 mg po qhs prn insomnia.
Tylenol 650 mg po q 4 hours prn pain or fever.
Milk of magnesia 30 cc po q 12 hours prn constipation.
Mylanta 30 cc po q 4 hours prn dyspepsia.

Restraint Orders
1. Type of Restraint: Seclusion, 4-point leather
restraint, or soft restraints.
2. Indication:
Confused, threat to self.
Agitated, threat to self.
Combative, threat to self/others.
Attempting to pull out tube, line, or dressing.
Attempting to get out of bed, fall risk.
3. Time
Begin at _____o’clock.
Not to exceed (specify number of hours).
4. Monitor patient as directed by hospital policy.
5. Staff may decrease or release restraints at their
discretion.
Restraint Notes
The restraint note should document that less restrictive
measures were attempted and failed or were considered,
but not appropriate for the urgent clinical situation.

Restraint Note

Date/time/writer:
The patient became agitated and, without
provocation, threw a chair and threatened several
patients verbally. He was unmanageable; therefore,
immediate 4-point restraints were required. Other
less-restrictive measures, such as locked seclusion,
were considered but deemed inappropriate given his
severe agitation and assaultive behavior. He will be
observed per protocol and may be released at staff’s
discretion. He will be given haloperidol (Haldol) 10
mg IM and lorazepam (Ativan) 2 mg IM because he
has refused oral medication.

Psychiatric Progress Notes

Daily progress notes should summarize the patient’s
current clinical condition and should review
developments in the patient's hospital course. The note
should address problems that remain active, plans to
treat those problems, and arrangements for discharge.
Progress notes should address every element of the
problem list.

Psychiatric Progress Note

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

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

Discharge Note
The discharge note should be written in the patient’s
chart prior to discharge.

Discharge Note

Date/time:
Diagnoses:
Treatment: Briefly describe therapy provided during
hospitalization, including psychiatric drug therapy,
and medical/surgical consultations and treatment.
Studies Performed: Electrocardiograms, CT scan,
psychological testing.
Discharge Medications:
Follow-up Arrangements:

Discharge Summary
The discharge summary reviews how a patient presented
to the hospital, salient psychosocial information, and the
course of treatment, diagnostic tests and response to
interventions are also discussed.

Patient's Name and Medical Record Number:

Date of Admission:
Date of Discharge:
DSM-IV Multiaxial Discharge Diagnosis
Axis I: Clinical disorders.
Other conditions that may be a focus of
clinical attention.
Axis II: Personality disorders.
Axis III: Medical conditions.
Axis IV: Psychosocial and environmental problems.
Axis V: Global assessment of functioning.
Attending or Ward Team Responsible for Patient:
Surgical Procedures, Diagnostic Tests, Invasive
Procedures:
History of Present Illness: Include salient features
surrounding reason for admission, past psychiatric
history, social history, mental status exam and physical
examination.
Diagnostic Data: Results of laboratory testing,
psychological testing, and brain imaging.
Hospital Course: Describe the course of the patient's
illness while in the hospital, including evaluation,
consultations, medications, outcome of treatment, and
unresolved issues at discharge. All items on the problem
list should be addressed.
Discharged Condition: Describe improvement or
deterioration in the patient's condition, and describe the
present status of the patient.
Disposition: Describe the situation to which the patient
will be discharged (home, nursing home), and indicate
who will take care of patient.
Legal Status at Discharge: Voluntary, involuntary,
conservatorship.
Discharge Medications: List medications, dosages,
quantities dispensed, and instructions.
Discharge Instructions and Follow-up Care: Date of
return for follow-up care at clinic; diet, exercise.
Copies: Send copies to attending, clinic, consultants.

Outpatient Progress Note

Subjective: The patient reports improved mood,

sleep, and appetite, but energy remains low. The
patient denies any side effects of medications other
than mild nausea that has been diminishing over the
past few days. The patient’s spouse reports
increased interest in usual activities.
Objective: The patient is casually dressed with good
grooming. Speech is more spontaneous, but output
is decreased. Mood remains depressed but improved
from the previous visit. Affect is brighter but still
constricted. Thinking is logical and goal directed. The
patient denies any recent suicidal or homicidal
ideation. No psychotic symptoms are noted.
Cognition is grossly intact. Insight is improving, and
judgment remains good.
Assessment: Major depression is improving with
nefazodone and supportive psychotherapy, but the
patient still has symptoms after 4 weeks of treatment
at 200 mg bid.
Plan: Increase nefazodone from 200 mg bid to 200
mg q AM and 400 mg qhs. Continue weekly
supportive therapy. Refer to senior center for
increased social interaction.

Psychological Testing
Psychological testing often provides additional
information that complements the psychiatric history and
mental status exam.

I. Psychological tests characterize psychological

symptoms, as well as describe personality and
motivations.
A. Rorschach Test. Ink blots serve as stimuli for
free associations; particularly helpful in
psychodynamic formulation and assessment of
defense mechanisms and ego boundaries.
B. Thematic Apperception Test (TAT). The patient
is asked to consider pictures of people in a
variety of situations, and is asked to make up a
story for each card. This test provides information
about needs, conflicts, defenses, fantasies, and
interpersonal relationships.
C. Sentence Completion Test (SCT). Patients are
asked to finish incomplete sentences, thereby
revealing conscious associations. Provides
insight into defenses, fears and preoccupations
of the patient.
D. Minnesota Multiphasic Personality Inventory
(MMPI). A battery of questions assessing
personality characteristics. Results are given in
10 scales.
E. Draw-a-Person Test (DAP). The patient is
asked to draw a picture of a person, and then to
draw a picture of a person of the opposite sex of
the first drawing. The drawings represent how the
patient relates to his environment, and the test
may also be used as a screening exam for brain
damage.
II. Neuropsychological tests assess cognitive
abilities and can assist in characterizing impaired
brain function.
A. Bender Gestalt Test. A test of visual-motor and
spatial abilities, useful for children and adults.
B. Halstead-Reitan Battery and Luria-Nebraska
Inventory
1. Standardized evaluation of brain functioning.
2. Assess expressive and receptive language,
memory, intellectual reasoning and judgment,
visual-motor function, sensory-perceptual
function and motor function.
 C. Wechsler Adult Intelligence Scale (WAIS).
Intelligence test that measures verbal IQ,
performance IQ, and full-scale IQ.
D. Wisconsin Card Sort. A test of frontal lobe
function.

References
References, see page 120.

Psychotic Disorders

Schizophrenia
Schizophrenia is a disorder characterized by apathy,
absence of initiative (avolition), and affective blunting.
These patients have alterations in thoughts, perceptions,
mood, and behavior. Many schizophrenics display
delusions, hallucinations and misinterpretations of reality.

I. DSM-IV Diagnostic Criteria for Schizophrenia

A. Two or more of the following symptoms present for
one month:
1. Delusions.
2. Hallucinations.
3. Disorganized speech.
4. Grossly disorganized or catatonic behavior.
5. Negative symptoms (ie, affective flattening,
alogia, avolition).
B. Decline in social and/or occupational functioning
since the onset of illness.
C. Continuous signs of illness for at least six months
with at least one month of active symptoms.
D. Schizoaffective disorder and mood disorder with
psychotic features have been excluded.
E. The disturbance is not due to substance abuse or a
medical condition.
F. If history of autistic disorder or pervasive
developmental disorder is present, schizophrenia
may be diagnosed only if prominent delusions or
hallucinations have been present for one month.
II. Clinical Features of Schizophrenia
A. A prior history of schizotypal or schizoid personality
traits or disorder is often present.
B. Symptoms of schizophrenia have been traditionally
categorized as either positive or negative.
Depression and neurocognitive dysfunction are
gaining acceptance as terms to describe two other
core symptoms of schizophrenia.
1. Positive symptoms
a. Hallucinations are most commonly auditory
or visual, but hallucinations can occur in any
sensory modality.
b. Delusions.
c. Disorganized behavior.
d. Thought disorder is characterized by loose
associations, tangentiality, incoherent
thoughts, neologisms, thought blocking,
thought insertion, thought broadcasting, and
ideas of reference.
2. Negative symptoms
a. Poverty of speech (alogia) or poverty of
thought content.
b. Anhedonia.
c. Flat affect.
d. Loss of motivation (avolition).
e. Attentional deficits.
f. Loss of social interest.
3. Depression is common and often severe in
schizophrenia and can compromise functional
status and response to treatment. Atypical
antipsychotics often improve depressive signs
and symptoms, but antidepressants may be
required.
4. Cognitive impairment. Cognitive dysfunction
(including attention, executive function, and
particular types of memory) contribute to
disability and can be an obstacle in long-term
treatment. Atypical antipsychotics may improve
cognitive impairment.
C. The presence of tactile, olfactory or gustatory
hallucinations may indicate an organic etiology
such as complex partial seizures.
D. Sensorium is intact.
E. Insight and judgment are frequently impaired.
F. No sign or symptom is pathognomonic of
schizophrenia.
III. Epidemiology of Schizophrenia
A. The lifetime prevalence of schizophrenia is one
percent.
B. Onset of psychosis usually occurs in the late teens
or early twenties.
 C. Males and females are equally affected, but the
mean age of onset is approximately six years later
in females. Females frequently have a milder
course of illness.
D. The suicide rate is 10-13%, similar to the rate that
occurs in depressive illnesses. More than 75% of
patients are smokers, and the incidence of
substance abuse is increased (especially alcohol,
cocaine, methamphetamine and marijuana).
E. Most patients follow a chronic downward course,
but some have a gradual improvement with a
decrease in positive symptoms and increased
functioning. Very few patients have a complete
recovery.
F. The lifespan for patients with schizophrenia is
approximately 10 years shorter compared to the
general population. This is thought to be related to
lifestyle (poor nutrition, lack of exercise, smoking
substance abuse), decreased access to medical
care and higher suicide rate.
IV.Classification of Schizophrenia
A. Paranoid type Schizophrenia
1. Characterized by a preoccupation with one or
more delusions or frequent auditory
hallucinations.
2. Paranoid type schizophrenia is characterized by
the absence of prominent disorganization of
speech, disorganized or catatonic behavior, or
flat or inappropriate affect.
B. Disorganized type Schizophrenia is
characterized by prominent disorganized speech,
disorganized behavior, and flat or inappropriate
affect.
C. Catatonic type Schizophrenia is characterized by
at least two of the following:
1. Motoric immobility.
2. Excessive motor activity.
3. Extreme negativism or mutism.
4. Peculiar voluntary movements such as bizarre
posturing.
5. Echolalia or echopraxia.
D. Undifferentiated type Schizophrenia meets
criteria for schizophrenia, but it cannot be
characterized as paranoid, disorganized, or
catatonic type.
E. Residual type Schizophrenia is characterized by
the absence of prominent delusions, disorganized
speech and grossly disorganized or catatonic
behavior and continued negative symptoms or two
or more attenuated positive symptoms.
V. Differential Diagnosis of Schizophrenia
A. Psychotic disorder due to a general medical
condition, delirium, or dementia. Included would
be CNS infections, thyrotoxicosis, lupus,
myxedema, multiple strokes, HIV, hepatic
encephalopathy, and others.
B. Substance-induced psychotic disorder.
Amphetamines and cocaine frequently cause
hallucinations, paranoia, or delusions.
Phencyclidine (PCP) may lead to both positive and
negative symptoms.
C. Schizoaffective disorder. Mood symptoms are
present for a significant portion of the illness. In
schizophrenia, the duration of mood symptoms is
brief compared to the entire duration of the illness.
D. Mood disorder with psychotic features
1. Psychotic symptoms occur only during major
mood disturbance (mania or major depression).
2. Disturbances of mood are frequent in all phases
of schizophrenia.
E. Delusional disorder. Non-bizarre delusions are
present in the absence of other psychotic
symptoms.
F. Schizotypal, paranoid, schizoid or borderline
personality disorders
1. Psychotic symptoms are generally mild and brief
in duration.
2. Patterns of behavior are life-long, with no
identifiable time of onset.
G. Brief psychotic disorder. Duration of symptoms is
between one day to one month.
H. Schizophreniform disorder. The criteria for
schizophrenia are met, but the duration of illness is
less than six months.
VI.Treatment of Schizophrenia
A. Pharmacotherapy. Antipsychotic medications
reduce core symptoms and are the cornerstone of
treatment of schizophrenia.
B. Psychosocial treatments in conjunction with
medications are often indicated. Day treatment
programs, with emphasis on social skills training,
can improve functioning and decrease relapse.
C. A complete discussion of the treatment of
Schizophrenia can be found on page 96.
 D. Family therapy and individual supportive
psychotherapy are also useful in relapse
prevention.
E. Electroconvulsive therapy is rarely used in the
treatment of schizophrenia, but may be useful
when catatonia or prominent affective symptoms
are present.
F. Indications for hospitalization
1. Psychotic symptoms prevent the patient from
caring for his basic needs.
2. Suicidal ideation, secondary to psychosis, often
requires hospitalization.
3. Patients who are a danger to themselves or
others require hospitalization.
4. Patients with command hallucinations to harm
self or others should be evaluated for
hospitalization, especially with a history of acting
on hallucinations.

Schizoaffective Disorder
I. DSM-IV Diagnostic Criteria
A. Schizoaffective disorder is an illness, which meets
the criteria for schizophrenia and concurrently
meets the criteria for a major depressive episode,
manic episode, or mixed episode.
B. The illness must also be associated with delusions
or hallucinations for two weeks, without significant
mood symptoms.
C. Mood symptoms must be present for a significant
portion of the illness.
D. A general medical condition or substance use is
not the cause of symptoms.
II. Clinical Features of Schizoaffective Disorder
A. Symptoms of schizophrenia are present, but the
symptoms are also associated with recurrent or
chronic mood disturbances.
B. Psychotic symptoms and mood symptoms may
occur independently or together.
C. If manic or mixed symptoms occur, they must be
present for one week, and major depressive
symptoms must be present for two weeks.
III. Epidemiology of Schizoaffective Disorder
A. The lifetime prevalence is under one percent.
B. First-degree biological relatives of schizoaffective
disorder patients have an increased risk of
schizophrenia as well as mood disorders.
IV.Classification of Schizoaffective Disorder
A. Bipolar Type. Diagnosed when a manic or mixed
episode occurs. Major depression may also occur.
B. Depressive type. Diagnosed if only major
depressive episodes occur.
V. Differential Diagnosis of Schizoaffective Disorder
A. Schizophrenia. In schizophrenia, mood symptoms
are relatively brief in relation to psychotic
symptoms. Mood symptoms usually do not meet
the full criteria for major depressive or manic
episodes.
B. Mood disorder with psychotic features. In mood
disorder with psychotic features, the psychotic
features occur only in the presence of a major
mood disturbance.
C. Delusional Disorder. Depressive symptoms can
occur in delusional disorders, but psychotic
symptoms of a delusional disorder are non-bizarre
compared to schizoaffective disorder.
D. Substance-Induced Psychotic Disorder.
Psychotic and mood symptoms of schizoaffective
disorder can also be mimicked by street drugs,
medications, or toxins.
E. Psychotic disorder due to a general medical
condition, delirium, or dementia should be ruled
out by medical history, physical exam, and labs.
VI.Treatment of Schizoaffective Disorder
A. Psychotic symptoms are treated with antipsychotic
agents (see Antipsychotic Therapy, page 96).
B. The depressed phase of schizoaffective disorder is
treated with antidepressant medications (see
Antidepressant Therapy, page 105).
C. For bipolar type, mood stabilizers (eg, lithium,
valproate or carbamazepine) are used alone or in
combination with antipsychotics (see Mood
Stabilizers, page 110).
D. Electroconvulsive therapy may be necessary for
severe depression or mania.
E. Hospitalization and supportive psychotherapy may
be required.
Schizophreniform Disorder
Patients with schizophreniform disorder meet full criteria
for schizophrenia, but the duration of illness is between
one and six months.

I. DSM-IV Diagnostic Criteria for Schizophreniform

Disorder
A. The following criteria for schizophrenia must be
met:
1. Two or more symptoms for one month.
Symptoms may include delusions,
hallucinations, disorganized speech, grossly
disorganized or catatonic behavior, or negative
symptoms.
2. Schizoaffective disorder and mood disorder with
psychotic features must be excluded.
3. Substance-induced symptoms or symptoms
from a general medical condition have been
ruled out.
4. Symptomatology must last for at least one
month, but less than six months.
II. Clinical Features of Schizophreniform Disorder
A. Symptomatology, including positive and negative
psychotic features, is the same as schizophrenia.
B. Social and occupational functioning may or may
not be impaired.
III. Epidemiology of Schizophreniform Disorder
A. Lifetime prevalence of schizophreniform disorder is
approximately 0.2%.
B. Prevalence is the same in males and females.
C. Depressive symptoms commonly coexist and are
associated with an increased suicide risk.
IV.Classification of Schizophreniform Disorder
A. Schizophreniform disorder with good
prognostic features
1. Onset of psychosis occurs within four weeks of
behavioral change.
2. Confusion often present at peak of psychosis.
3. Good premorbid social and occupational
functioning.
4. Lack of blunted or flat affect.
B. Schizophreniform disorder without good prognostic
features is characterized by the absence of above
features.
V. Differential Diagnosis of Schizophreniform
Disorder
A. The differential diagnosis for schizophreniform
disorder is the same as for schizophrenia and
includes psychotic disorder due to a general
medical condition, delirium, or dementia.
B. Substance abuse, medication or toxic substances
may cause symptoms that are similar to
schizophreniform disorder.
C. Concomitant use of drugs that can cause or
exacerbate psychosis, such as amphetamines,
may complicate the diagnostic process.
VI.Treatment of Schizophreniform Disorder
A. Antipsychotic medication in conjunction with
supportive psychotherapy is the primary treatment
(see Antipsychotic Therapy, page 96).
B. Hospitalization may be required if the patient is
unable to care for himself or if suicidal or homicidal
ideation is present.
C. Depressive symptoms may require antidepressants
or mood stabilizers.
D. Early and aggressive treatment is associated with a
better prognosis.
Brief Psychotic Disorder
Brief psychotic disorder is characterized by
hallucinations, delusions, disorganized speech or
behavior. Symptom onset is often rapid, with marked
functional impairment. The duration of symptoms is
between one day and one month. In contrast, diagnosis
of schizophrenia requires a six-month duration of
symptoms.

I. DSM-IV Diagnostic Criteria for Brief Psychotic

Disorder
A. At least one of the following:
1. Delusions.
2. Hallucinations.
3. Disorganized speech.
4. Grossly disorganized or catatonic behavior.
B. Duration of symptoms is between one day and one
month, after which the patient returns to the
previous level of functioning.
C. The disturbance is not caused by a mood disorder
with psychotic features, substance abuse,
schizoaffective disorder, schizophrenia, or other
medical condition.
II. Clinical Features of Brief Psychotic Disorder
 A. Emotional turmoil and confusion are often present.
B. Mood and affect may be labile.
C. Onset is usually sudden and may abate as rapidly
as it began.
D. Attentional deficits are common.
E. Psychotic symptoms are usually of brief duration
(several days).
III. Epidemiology of Brief Psychotic Disorder
A. The disorder is rare, and younger individuals have
a higher rate of illness, with the average age of
onset in the late twenties to early thirties.
B. The risk of suicide is increased in patients with this
disorder, especially in young patients.
C. Patients with personality disorders have a higher
risk for brief psychotic disorder.
IV.Classification of Brief Psychotic Disorder
A. Brief Psychotic Disorder with Marked Stressors
is present if symptoms occur in relation to severe
stressors (ie, death of a loved one).
B. Brief Psychotic Disorder without Marked
Stressors is present if symptoms occur without
identifiable stressors.
C. Brief Psychotic Disorder with Postpartum
Onset occurs within four weeks of giving birth.
V. Differential Diagnosis of Brief Psychotic Disorder
A. Substance-Induced Psychotic Disorder
1. Amphetamine, cocaine and PCP may produce
symptoms indistinguishable from brief psychotic
disorder. Alcohol or sedative hypnotic
withdrawal may also mimic these symptoms.
2. Substance abuse should be excluded by history
and with a urine toxicology screen.
B. Psychotic Disorder Caused a General Medical
Condition
1. Rule out with history, physical exam and labs. A
CBC can be used to rule out delirium and
psychosis caused by infection. This is especially
important in elderly patients where the incidence
of brief reactive psychosis is low compared to
younger patients.
2. Routine chemistry labs can be used to rule out
electrolyte imbalances or hepatic
encephalopathy; RPR to rule out neurosyphilis;
HIV to rule out psychosis due to encephalitis in
at-risk patients.
3. Consider an MRI or head CT scan to rule out a
mass or neoplasm.
4. An EEG should be considered to rule out
seizure disorders (such as temporal lobe
epilepsy), especially when there is a history of
amnestic periods or impaired consciousness.
C. Schizophreniform Disorder or Schizophrenia.
Schizophreniform disorder must last for over a
month, and schizophrenia must have a six- month
duration.
D. Mood Disorder with Psychotic Features. Brief
psychotic disorder cannot be diagnosed if the full
criteria for major depressive, manic or mixed
episode is present
VI.Treatment of Brief Psychotic Disorder
A. Brief hospitalization may be necessary, especially if
suicidal or homicidal ideation is present. Patients
can also be very confused and impulsive.
B. A brief course of a neuroleptic, such as risperidone
(Risperdal) 2-4 mg per day, is usually indicated.
Adjunctive benzodiazepines can speed the
resolution of symptoms. Short-acting
benzodiazepines, such as lorazepam 1-2 mg every
4 to 6 hours, can be used as needed for associated
agitation and anxiety.
C. Supportive psychotherapy is indicated if
precipitating stressors are present. Supportive
psychotherapy is initiated after psychosis has
resolved.

Delusional Disorder
Delusional disorder is characterized by the presence of
irrational, untrue beliefs.

I. DSM-IV Diagnostic Criteria for Delusional Disorder

A. Non-bizarre delusions have lasted for at least one
month.
B. This disorder is characterized by the absence of
hallucinations, disorganized speech, grossly
disorganized or catatonic behavior, or negative
symptoms of schizophrenia (tactile or olfactory
hallucinations may be present if related to the
delusional theme).
C. Behavior and functioning are not significantly
bizarre or impaired.
D. If mood episodes have occurred, the total duration
of mood pathology is brief compared to the
 duration of the delusions.
II. Clinical Features of Delusional Disorder
A. The presence of a non-bizarre delusion is the
cardinal feature of this disorder. The delusion must
be plausible, such as believing that someone is
trying to harm them.
B. Patient’s thought processes and thought content
are normal except when discussing the specific
delusion.
C. Hallucinations are not prominent unless delusional
disorder is of the somatic type. Cognition and
sensorium are intact.
D. There is generally no disturbance of thought
processes, such as loosening of associations or
tangentiality.
E. The insight of patients into their illness is generally
poor, and this disorder may cause significant
impairment in social and occupational functioning.
III. Epidemiology of Delusional Disorder
A. Delusional disorder is uncommon, with a
prevalence of 0.03%.
B. Mean age of onset is generally between 35-45;
however, age of onset is highly variable. The
incidence in males and females appears equal.
IV.Classification of Delusional Disorder
A. Persecutory type. Involves delusions that the
individual is being harassed.
B. Somatic type. Involves delusions of a physical
deficit or medical condition.
C. Erotomanic type. Involves delusions that another
person is in love with the patient.
D. Grandiose type. Involves delusions of
exaggerated power, wealth, knowledge, identity or
relationship to a famous person or religious figure.
E. Jealous type. Involves delusions that an
individual’s partner is unfaithful.
F. Mixed type. Involves delusions of at least two of
the above without a predominate theme.
V. Differential Diagnosis of Delusional Disorder
A. Schizophrenia/Schizophreniform Disorder.
Delusional disorder is distinguished from these
disorders by a lack of other positive or negative
symptoms of psychosis.
B. Substance-Induced Psychotic Disorder
1. Symptoms may be identical to delusional
disorder if the patient has ingested
amphetamines or cocaine.
2. Substance abuse should be excluded by history
and toxicology.
C. Psychotic Disorder Due to a General Medical
Condition
1. Simple delusions of a persecutory or somatic
nature are often present in delirium or dementia.
2. Cognitive exam, history and physical
examination can usually distinguish these
conditions.
D. Mood Disorders With Psychotic Features.
Although mood symptoms and delusions may be
present in both disorders, patients with delusional
disorder do not meet full criteria for a mood
episode, and the duration of mood symptoms is
brief compared to delusional symptoms.
VI.Treatment of Delusional Disorder
A. Delusional disorders are often refractory to
antipsychotic medication.
B. Psychotherapy, including family or couples therapy,
may offer some benefit.

References
References, see page 120.

Mood Disorders
I. Categorization of Mood Disorders
A. Mood episodes are comprised of periods when
the patient exhibits symptoms of a predominant
mood state. Mood episodes are not diagnostic
entities. The mood disorders are clinical diagnoses
defined by the presence of characteristic mood
episodes.
B. Mood episodes are classified as follows:
1. Types of Mood Episodes
a. Major Depressive Episode.
b. Manic Episode.
c. Mixed Episode.
d. Hypomanic Episode.
C. Mood disorders are classified as follows:
1. Types of Mood Disorders
a. Depressive Disorders.
b. Bipolar Disorders.
c. Other Mood Disorders.
Major Depressive Episodes
Major depressive episodes are characterized by
persistent sadness, often associated with somatic
symptoms, such as weight loss, difficulty sleeping and
decreased energy.

I. DSM-IV Diagnostic Criteria

A. At least five of the following symptoms for at least
two weeks duration.
B. Must be a change from previous functioning.
C. At least one symptom is depressed mood or loss of
interest or pleasure.
1. Pervasive depressed mood.
2. Pervasive anhedonia.
3. Significant change in weight.
4. Sleep disturbance.
5. Psychomotor agitation or retardation.
6. Pervasive fatigue or loss of energy.
7. Excessive guilt or feelings of worthlessness.
8. Difficulty concentrating.
9. Recurrent thoughts of death or thoughts of
suicide.
D. Symptoms must cause significant social or
occupational dysfunction or significant subjective
distress.
E. Cannot be caused by a medical condition,
medication or drugs.
F. Symptoms cannot be caused by bereavement.
II. Clinical Features of Depressive Episodes
A. Occasionally no subjective depressed mood is
present; only anxiety and irritability are displayed.
B. Feelings of hopelessness and helplessness are
common.
C. Decreased libido is common.
D. Early morning awakening with difficulty or inability
to fall back asleep is typical.
E. Psychomotor agitation can be severe.
F. Patients may appear demented because of poor
attention, poor concentration, and indecisiveness.
G. Guilt may become excessive and may appear
delusional.
H. Obsessive rumination about the past or specific
problems is common.
I. Preoccupation with physical health may occur.
J. Frank delusions and hallucinations may occur, and
they are frequently nihilistic in nature.
K. Family history of mood disorder or suicide is
common.

Manic Episodes
I. DSM-IV Diagnostic Criteria
A. At least one week of abnormally and persistently
elevated, expansive or irritable mood (may be less
than one week if hospitalization is required).
B. During the period of mood disturbance, at least
three of the following have persisted in a significant
manner (four if mood is irritable):
1. Inflated self-esteem or grandiosity.
2. Decreased need for sleep.
3. The patient has been more talkative than usual
or feels pressure to keep talking.
4. Flight of ideas (jumping from topic to topic) or a
subjective sense of racing thoughts.
5. Distractibility.
6. Increased goal-directed activity or psychomotor
agitation.
7. Excessive involvement in pleasurable activities
with a high potential for painful consequences
(ie, sexual indiscretion).
C. Does not meet criteria for a mixed episode.
D. Symptoms must have cause marked impairment in
social or occupational functioning, or have required
hospitalization to prevent harm to self or others, or
psychotic features are present.
E. The symptoms cannot be caused by a medical
condition, medication or drugs.
II. Clinical Features of Manic Episodes
A. The most common presentation is excessive
euphoria, but some patients may present with
irritability alone.
B. Patients may seek out constant enthusiastic
interaction with others, frequently using poor
judgment in those interactions.
C. Increased psychomotor activity can take the form
of excessive planning and participation, which are
ultimately nonproductive.
D. Reckless behavior with negative consequences is
common (eg, shopping sprees, excessive
 spending, sexual promiscuity).
E. Inability to sleep can be severe and persist for
days.
F. Lability of mood is common.
G. Grandiose delusions are common.
H. Speech is pressured, loud and intrusive, and
difficulty interrupting these patients is common.
Flight of ideas can result in gross disorganization
and incoherence of speech.
I. Patients frequently lack insight into their behavior
and resist treatment.
J. Patients may become grossly psychotic, most
frequently with paranoid features.
K. Patients may become assaultive, particularly if
psychotic.
L. Dysphoria is common at the height of a manic
episode, and the patient may become suicidal.

Hypomanic Episodes
I. DSM-IV Diagnostic Criteria
A. At least 4 days of abnormally and persistently
elevated, expansive or irritable mood.
B. During the period of mood disturbance at least
three of the following have persisted in a significant
manner (four if mood is irritable):
1. Inflated self-esteem or grandiosity.
2. Decreased need for sleep.
3. The patient is more talkative than usual and
feels pressure to keep talking.
4. Flight of ideas (jumping from topic to topic) or a
subjective sense of racing thoughts.
5. Distractibility.
6. Increased goal-directed activity or psychomotor
agitation.
7. Excessive involvement in pleasurable activities
that have a high potential for painful
consequences (ie, sexual promiscuity).
C. The mood disturbance and change in functioning is
noticeable to others.
D. The change in functioning is uncharacteristic of the
patient’s baseline but does not cause marked
social or occupational dysfunction, does not require
hospitalization, and no psychotic features are
present.
E. Symptoms cannot be due to a medical condition,
medication or drugs.
II. Clinical Features of Hypomanic Episodes
A. The major difference between hypomanic and
manic episodes is the lack of major social and/or
occupational dysfunction in hypomania, which is
hallmark of a manic episode. Hallucinations and
delusions are not seen in hypomania.

Mixed Mood Episodes

I. DSM-IV Diagnostic Criteria
A. Patient meets criteria for both for at least one
week.
B. Symptoms are severe enough to cause marked
impairment in occupational or social functioning,
require hospitalization, or psychotic features are
present.
C. Organic factors have been excluded (medical
conditions, medications, drugs).
II. Clinical Features of Mixed Mood Episodes
A. Patients subjectively experience rapidly shifting
moods.
B. They frequently present with agitation, psychosis,
suicidality, appetite disturbance and insomnia.

Major Depressive Disorder

I. DSM-IV Diagnostic Criteria for Major Depressive
Disorders
A. History of one or more Major Depressive Episodes.
B. No history of manic, hypomanic, or mixed
episodes.
II. Clinical Features of Major Depressive Disorder
A. Major depressive disorder has a high mortality;
15% suicide rate. Common coexisting diagnoses
include panic disorder, eating disorders,
substance-related disorders. These disorders
should be excluded by the clinical history.
B. Major depressive disorder often complicates the
presentation and treatment of patients with medical
conditions, such as myocardial infarction, stroke,
and diabetes.
C. The disorder often follows an episode of severe
stress, such as loss of a loved one.
 D. All patients should be asked about suicidal ideation
as well as intent. Hospitalization may be necessary
for acutely suicidal patients. Suicide risk may
increase as the patient begins to respond to
treatment. Lack of initiative and poor energy can
improve prior to improvement in mood, allowing
patients to follow through on suicidal ideas.
E. Suicide risk is most closely related to the degree of
hopelessness a patient is experiencing and not to
the severity of depression.
III. Epidemiology of Major Depressive Disorder
A. Prevalence is approximately 3-6%, with a 2:1
female-to-male ratio.
B. Approximately 50% of patients who have a single
episode of major depressive disorder will have a
recurrence. This rises to 70% after two episodes
and 90% after three episodes.
C. Functioning returns to the premorbid level between
episodes in approximately two-thirds of patients.
D. The disorder is two times more common in first-
degree relatives of patients with major depressive
disorder compared to the general population.
IV.Classification of Major Depressive Disorder
A. Major Depressive Disorder with Psychotic
Features. Depression is accompanied by
hallucinations or delusions, which may be mood-
congruent (content is consistent with typical
depressive themes) or mood incongruent (content
does not involve typical depressive themes).
B. Major Depressive Disorder, Chronic. Full
diagnostic criteria for major depressive disorder
have been met continuously for at least 2 years.
C. Major Depressive Disorder with Catatonic
Features
Accompanied by at least two of the following:
1. Motor immobility or stupor.
2. Excessive purposeless motor activity.
3. Extreme negativism or mutism.
4. Bizarre or inappropriate posturing, stereotyped
movement, or facial grimacing.
5. Echolalia or echopraxia.
D. Major Depressive Disorder with Melancholic
Features. Depression is accompanied by severe
anhedonia or lack of reactivity to usually
pleasurable stimuli and at least three of the
following:
1. Quality of mood is distinctly depressed.
2. Mood is worse in the morning.
3. Early morning awakening.
4. Marked psychomotor slowing.
5. Significant weight loss.
6. Excessive guilt.
E. Major Depressive Disorder with Atypical
Features. Depression is accompanied by mood
reactivity and at least two of the following:
1. Significant weight gain.
2. Hypersomnia.
3. “Heavy” feeling in extremities (leaden paralysis).
4. Chronic pattern of rejection sensitivity, resulting
in significant social or occupational dysfunction.
5. Does not meet criteria for major depressive
disorder with melancholic or catatonic features.
F. Major Depressive Disorder with Postpartum
Onset. Onset of episode within four weeks of
parturition.
G. Major Depressive Disorder with Seasonal
Pattern
1. Recurrent episodes of depression with a pattern
of onset at same time each year.
2. Full remissions occur at a characteristic time of
year.
3. Over a two-year period, at least two seasonal
episodes have occurred, and no nonseasonal
episodes have occurred.
4. Seasonal episodes outnumber non-seasonal
episodes.
V. Differential Diagnosis of Major Depressive
Disorder
A. Bereavement
1. Bereavement may share many symptoms of a
major depressive episode.
2. Normal bereavement should not present with
depressive symptoms, which cause severe
functional impairment lasting more than two
months.
B. Adjustment Disorder with Depressed Mood
1. A stressful event may precede the onset of a
major depressive episode; however, dysphoria
related to a stressor that does not meet the
criteria for major depressive episode should be
diagnosed as an adjustment disorder.
C. Anxiety Disorders
1. Symptoms of anxiety frequently coexist with
depression.
 2. When anxiety symptoms coexist with depressive
symptoms, the depression should be the focus
of treatment because it carries a higher
morbidity and mortality. Antidepressants are
often effective in treating anxiety disorders.
D. Schizophrenia and Schizoaffective Disorder
1. Subjective depression may accompany acute
psychosis. Severe psychotic depression may be
difficult to distinguish from a primary psychotic
disorder.
2. In psychotic depression, the mood symptoms
generally precede the onset of psychotic
symptoms.
3. The premorbid and inter-episode functioning
are generally higher in patients with mood
disorders, compared to patients with psychotic
disorders.
E. Dementia
1. Dementia and depression may present with
complaints of apathy, poor concentration, and
impaired memory.
2. Cognitive deficits due to a mood disorder may
appear very similar to dementia.
“Pseudodementia” is defined as depression that
mimics dementia.
3. Differentiation of dementia from depression can
be very difficult in the elderly. When the
diagnosis is unclear, a trial of antidepressants
may be useful because depression is reversible
and dementia is not.
4. The medical history and examination can
suggest possible medical or organic causes of
dementia.
F. Mood Disorder Due to a General Medical
Condition
1. The medical history and examination may
suggest potential medical conditions which
present with depressive symptoms.
2. This diagnosis applies when the mood disorder
is a direct physiological consequence of the
medical disorder and is not an emotional
response to a physical illness. For example,
Parkinson’s disease is often associated with a
depressive syndrome, which is not simply a
reaction to the disability of the disease.
G. Substance-Induced Mood Disorder
1. Careful examination of all medications, drugs of
abuse, or toxin exposure should be completed.
2. Alcohol, drug abuse, sedatives,
antihypertensives, and oral contraceptives can
all cause depressive symptoms.
3. Withdrawal from sympathomimetics or
amphetamines may cause a depressive
syndrome.
VI.Pharmacotherapy of Depression
A. For a complete discussion of the treatment of
Depression, see Antidepressant Therapy, page
105.
B. Selecting an Antidepressant Agent
1. All antidepressant drugs have shown equal
efficacy, but the various agents have different
side-effect profiles.
2. There is no reliable method of predicting which
patients will respond to a specific
antidepressant based on clinical presentation. If
the patient or a first-degree relative has had a
previous treatment response to a given
medication, another trial of that medication is
indicated.
3. Agent selection is also based on the expected
tolerance to side effects, the patient’s age,
suicide potential, and any coexisting diseases or
medications.
a. Selective-serotonin reuptake inhibitors
(SSRIs) are much safer than heterocyclic
antidepressants in patients with a history of
cardiac disease.
b. SSRIs are safer than heterocyclic
antidepressants in overdose, making them
preferable for suicidal patients.
C. Classification of Antidepressant Agents
1. Heterocyclic Antidepressants
a. Side effects (especially sedation and
anticholinergic effects) are worse during the
first month of therapy and usually diminish
after four weeks.
b. Early in the treatment course, patients may
sleep better, but patients rarely describe
improvement in mood before 3-4 weeks.
c. The potential of tricyclics to be fatal in
overdose limits the quantity that should be
prescribed, particularly in patients with
suicidal ideation or a history of suicide
attempts.
d. Use of heterocyclic antidepressants in the
 elderly may be limited by the sensitivity of
these patients to anticholinergic and cardio-
vascular side effects.
2. Selective-Serotonin Reuptake Inhibitors
(SSRIs)
a. SSRIs are first-line agents and include
fluoxetine (Prozac), sertraline (Zoloft),
paroxetine (Paxil), fluvoxamine (Luvox), cita-
lopram (Celexa), and escitalopram
(Lexapro).
b. SSRIs, with their comparatively benign side-
effect profile, allow once-daily dosing and
present less danger from overdose because
they have reduced seizure potential and lack
the cardiovascular toxicity of the tricyclics in
overdose.
c. Another advantage of SSRIs is that they
require less dosage titration. Thus, a
therapeutic dose may be achieved earlier
than with tricyclics.
d. Although many patients take SSRIs with no
adverse consequences, the most frequent
side effects are insomnia, headache, GI
upset, anxiety, agitation, and sexual dys-
function.
3. Atypical Agents
a. Bupropion (Wellbutrin, Wellbutrin SR, and
Wellbutrin XL): Bupropion is a mildly
stimulating antidepressant and is particularly
useful in patients who have had sexual
impairment from other drugs. The short half-
life of bupropion requires multiple daily
doses, complicating compliance. There is a
low incidence of sexual dysfunction and
possible decreased liability to precipitate
mania.
b. Venlafaxine (Effexor, Effexor XR):
Venlafaxine is a selective inhibitor of
serotonin reuptake with norepinephrine
reuptake inhibition occurring at doses > 200
mg/day. Insomnia, nervousness and nausea
are common. At higher doses, it can elevate
diastolic blood pressure and requires
monitoring of blood pressure.
c. Nefazodone: Nefazodone is a serotonergic
antidepressant, but it is not considered a
SSRI because of other receptor effects. It
tends to be more sedating than the SSRIs,
and it can have a calming or antianxiety
effect in some patients. It is also useful in
patients who experience sexual impairment
with other antidepressants. Rare cases of
liver failure have been reported with
nefazodone (one case of death or liver
transplant per 250,000-300,000 patient-
years of nefazodone exposure).
d. Mirtazapine (Remeron): Mirtazapine is a
selective alpha-2- adrenergic antagonist,
which enhances noradrenergic and
serotonergic neurotransmission. Sedation
and enhanced appetite are inversely
proportional to dose, prompting some
clinicians to forgo dose titration. There is a
low incidence of sexual dysfunction.
e. Duloxetine (Cymbalta): Duloxetine is a
norepinephrine and serotonin reuptake
inhibitor at all doses. It is indicated for major
depression and neuropathic pain. Most
common side effects include nausea, and
insomnia.
4. Monoamine Oxidase Inhibitors (MAOIs)
a. Contraindications and dietary restriction
discourage common use.
b. Side Effects. Orthostatic hypotension is
common. A tyramine-free diet is required to
prevent hypertensive crisis.
c. Drug Interactions. Coadministration of
epinephrine, meperidine (Demerol), and
SSRIs can be life-threatening.
VII. Electroconvulsive Therapy for Depression (also
see Electroconvulsive Therapy, page 118). ECT is
a safe and very effective treatment for depression,
especially if there is a high risk for suicide or
insufficient time for a trial of medication.
VIII. Psychotherapy for Major Depressive Disorder
A. A wide variety of psychotherapies are effective in
the treatment of major depressive disorder,
especially cognitive behavioral psychotherapy and
insight oriented psychotherapy.
B. Combined pharmacotherapy and psychotherapy is
the most effective treatment for major depressive
disorder, after ETC.
Dysthymic Disorder
I. DSM-IV Diagnostic Criteria
A. Depressed mood is present for most of the day, for
more days than it is not present, and depression
has been present for at least two years.
B. Presence of at least two of the following:
1. Poor appetite or overeating.
2. Insomnia or hypersomnia.
3. Low energy or fatigue.
4. Low self-esteem.
5. Poor concentration or difficulty making
decisions.
6. Hopelessness.
C. Over the two-year period, the patient has never
been without symptoms for more than two months
consecutively.
D. No major depressive episode has occurred during
the first two years of the disturbance.
E. No manic, hypomanic or mixed episode, or
evidence of cyclothymia is present.
F. Symptoms do not occur with a chronic psychotic
disorder.
G. Symptoms are not due to substance use or a
general medical condition.
H. Symptoms cause significant social or occupational
dysfunction or marked subjective distress.
II. Clinical Features of Dysthymic Disorder
A. Symptoms of dysthymic disorder are similar to
those of major depression. The most common
symptoms are loss of pleasure in usually
pleasurable activities, feelings of inadequacy,
social withdrawal, guilt, irritability, and decreased
productivity.
B. Changes in sleep, appetite or psychomotor
behavior are less common than in major
depressive disorder.
C. Patients often complain of multiple physical
problems, which may interfere with occupational or
social functioning. Psychotic symptoms are not
present.
D. Episodes of major depression may occur after the
first two years of the disorder. The combination of
dysthymia and major depression is known as
“double depression.”
III. Epidemiology of Dysthymic Disorder
A. Lifetime prevalence is 6%, with a female-to-male
ratio of 3:1.
B. Onset usually occurs in childhood or adolescence.
C. Dysthymia that occurs prior to the onset of major
depression has a worse prognosis than major
depression without dysthymia.
IV.Classification of Dysthymic Disorder
A. Early Onset Dysthymia: Onset occurs before age
21.
B. Late Onset Dysthymia: Onset occurs at age 21 or
older.
C. Dysthymia with Atypical Features is accompanied
by mood reactivity and at least two of the following:
1. Significant weight gain.
2. Hypersomnia.
3. “Leaden” paralysis, characterized by a feeling of
being heavy or weighted down physically.
4. A chronic pattern of rejection sensitivity, which
often results in significant social or occupational
dysfunction.
V. Differential Diagnosis of Dysthymic Disorder
A. Major Depressive Disorder. Dysthymia leads to
chronic, less severe depressive symptoms,
compared to Major Depression. Major Depression
usually has one of more discrete episodes.
B. Substance-Induced Mood Disorder. Alcohol,
benzodiazepines and other sedative-hypnotics can
mimic dysthymia symptoms, as can chronic use of
amphetamines or cocaine. Anabolic steroids, oral
contraceptives, methyldopa, beta-adrenergic
blockers and isotretinoin (Accutane) have also
been linked to depressive symptoms. Substance-
Induced Mood Disorder should be excluded with a
careful history of drugs of abuse and medications.
C. Mood Disorder Due to a General Medical
Condition. Depressive symptoms consistent with
dysthymia may occur in stroke, Parkinson’s
disease, multiple sclerosis, Huntington’s disease,
vitamin B12 deficiency, hypothyroidism, Cushing’s
disease, pancreatic carcinoma, and HIV. These
disorders should be ruled out with a history,
physical examination, and labs as indicated.
D. Psychotic Disorders. Depressive symptoms are
common in chronic psychotic disorders, and
dysthymia should not be diagnosed if symptoms
occur only during psychosis.
E. Personality Disorders. Personality disorders
frequently coexist with dysthymic disorder.
VI.Treatment of Dysthymic Disorder
A. Hospitalization is usually not required unless
suicidality is present.
B. Antidepressants. Many patients respond well to
antidepressants. SSRIs are most often used. If
these or other antidepressants, such as
venlafaxine, nefazodone or bupropion, have failed,
then a tricyclic antidepressant, such as
desipramine, 150 to 200 mg per day, is often
effective. (For a complete discussion of
antidepressant therapy, see page 105.)
C. Psychotherapy: Cognitive psychotherapy may
help patients deal with incorrect negative attitudes
about themselves. Insight oriented psychotherapy
may help patients resolve early childhood conflict,
which may have precipitated depressive symptoms.
Combined psychotherapy and pharmacotherapy
produces the best outcome.

Bipolar I Disorder
Bipolar I Disorder is a disorder in which at least one
manic or mixed episode is present.

I. DSM-IV Criteria for Bipolar I Disorder

A. One or more manic or mixed episodes.
B. The disorder is commonly accompanied by a
history of one or more major depressive episodes,
but a major depressive episode is not required for
the diagnosis.
C. Manic or mixed episodes cannot be due to a
medical condition, medication, drugs of abuse,
toxins, or treatment for depression.
D. Symptoms cannot be caused by a psychotic
disorder.
II. Clinical Features of Bipolar I Disorder
A. The first mood episode in bipolar disorder is often
depression, especially in women.
B. Ninety percent of patients who have a single manic
episode will have a recurrence.
C. Bipolar disorder is often diagnosed over time.
Studies find that 10 years may elapse between the
first mood episode and the diagnosis of bipolar.
D. Episodes occur more frequently with age.
E. Manic episodes can result in violence, child abuse,
excessive debt, job loss, or divorce.
F. Mixed episodes are more likely in younger patients.
G. The suicide rate of bipolar patients is 10-15%.
H. Common comorbid diagnoses often include
substance-related disorders, eating disorders, and
attention deficit hyperactivity disorder.
I. Bipolar I disorder with a rapid cycling pattern
carries a poor prognosis and may affect up to 20%
of bipolar patients.
J. A thorough past psychiatric and family history is
essential when evaluating a patient with mood
disorder.
III. Epidemiology of Bipolar I Disorder
A. The lifetime prevalence of bipolar disorder is
approximately 0.5-1.5%.
B. The male-to-female ratio is 1:1
C. The first episode in males tends to be a manic
episode, while the first episode in females tends to
be a depressive episode.
D. First-degree relatives have higher rates of mood
disorder. Bipolar disorder has a 70% concordance
rate among monozygotic twins.
IV.Classification of Bipolar I Disorder
A. Classification of bipolar I disorder involves
describing the current or most recent mood
episode as either manic, hypomanic, mixed or
depressive (eg, Bipolar I disorder- most recent
episode mixed).
B. The most recent episode can be further
classified as follows:
1. Without psychotic features.
2. With psychotic features.
3. With catatonic features.
4. With postpartum onset.
C. Bipolar I Disorder with Rapid Cycling
1. Diagnosis requires the presence of at least four
mood episodes within one year.
2. Rapid cycling mood episodes may include major
depressive, manic, hypomanic, or mixed
episodes
3. The patient must be symptom-free for at least
two months between episodes, or the patient
must switch to an opposite episode.
V. Differential Diagnosis of Bipolar I Disorder
A. Cyclothymic Disorder. This disorder may cause
manic-like episodes that do not meet the criteria for
manic episode, depressive episodes, or major
depression.
 B. Psychotic Disorders
1. The clinical presentation of a patient at the
height of a manic episode may be
indistinguishable from that of an acute
exacerbation of paranoid schizophrenia.
2. If the history is unavailable or if the patient is
having an initial episode, it may be necessary to
observe the patient over time to make an
accurate diagnosis. A subsequent major
depressive episode or manic episode that
initially presents with mood symptoms prior to
the onset of psychosis, indicates that a mood
disorder, rather than a psychotic disorder, is
present.
3. A family history of either a mood disorder or
psychotic disorder suggests the diagnosis of
bipolar disorder or psychotic disorder,
respectively.
C. Substance-Induced Mood Disorder. The effects
of medication or drugs of abuse should be
excluded. Common organic causes of mania
include sympathomimetics, amphetamines,
cocaine, steroids, and H2 blockers (eg, cimetidine).
D. Mood Disorder Due to a General Medical
Condition. Medical conditions that may present
with manic symptoms include AIDS, Cushing’s,
hyperthyroidism, lupus, multiple sclerosis, and
brain tumors.
VI.Treatment of Bipolar I Disorder
A. Hospitalization may be necessary for either Manic
or Depressive mood episodes.
B. Assessment of suicidality is essential; suicidal
ideation and intent should be evaluated.
Medications reduce the incidence of suicide in
bipolar disorder.
C. Pharmacotherapy
1. Traditional mood stabilizers, such as lithium and
the anticonvulsants, are effective for acute
treatment as well as the prophylaxis of mood
episodes. (Also see Mood Stabilizers, page
110). Mood stabilizers are more effective in
preventing and treating manic episodes than
they are for depressive episodes. Lamotrigine
is modestly effective in treating bipolar
depression, but more so than lithium and other
anticonvulsants.
2. Antidepressants may be used for treatment of
major depressive episodes, but they should only
be used in conjunction with a mood stabilizer to
prevent precipitation of a manic episode.
Tricyclics and serotonin-norepinephrine
reuptake inhibitors (venlafaxine and duloxetine)
may have higher risk for precipitating mania.
Antidepressants may induce rapid cycling.
3. All atypical antipsychotics are effective in acute
mania. Aripiprazole and olanzapine are
approved for maintenance treatment and data
are accumulating that other atypicals are
effective as well for long-term use. The
combination medication olanzapine-fluoxetine is
approved for treatment of bipolar depression.
4. Sedating benzodiazepines, such as
clonazepam and lorazepam, may be used
adjunctively for severe agitation associated with
acute mania.
5. ECT is very effective for bipolar disorder
(depressed or manic episodes), but it is
generally used after conventional
pharmacotherapy has failed or is
contraindicated.
D. Psychotherapy
1. Therapy aimed at increasing insight and dealing
with the consequences of the manic episodes
may be very helpful.
2. Family or marital therapy may also help
increase understanding and tolerance of the
affected family member.

Bipolar II Disorder
I. DSM-IV Diagnostic Criteria of Bipolar II Disorder
A. One or more major depressive episodes and at
least one hypomanic episode.
B. Mood episodes cannot be caused by a medical
condition, medication, drugs of abuse, toxins, or
treatment for depression.
C. Symptoms cannot be caused by a psychotic
disorder.
II. Clinical Features of Bipolar II Disorder
A. Hypomanic episodes tend to occur in close
proximity to depressive episodes, and episodes
tend to occur more frequently with age.
B. Social and occupational consequences of bipolar II
 can include job loss and divorce. These patients
have a suicide rate of 10-15%.
C. Common comorbid diagnoses include substance-
related disorders, eating disorders, attention deficit
hyperactivity disorder, and borderline personality
disorder.
D. The rapid cycling pattern carries a poor prognosis.
III. Epidemiology. The lifetime prevalence of bipolar II is
0.5%. It is more common in women than in men.
IV.Classification of Bipolar II Disorder
A. Classification of bipolar II disorder involves
evaluation of current or most recent mood episode,
which can be hypomanic or depressive.
B. The most recent episode can be further
classified as follows:
1. Episodes without psychotic features.
2. Episodes with psychotic features.
3. Episodes with catatonic features.
4. Episodes with post partum onset.
C. Bipolar II Disorder with Rapid Cycling
1. This diagnosis requires the presence of at least
four mood episodes within one year. Episodes
may include major depressive, manic,
hypomanic, or mixed type episodes.
2. The patient must be symptom-free for at least
two months between episodes, or the patient
must display a change in mood to an opposite
type of episode.
V. Differential Diagnosis of Bipolar II Disorder
A. Cyclothymic Disorder. These patients will exhibit
mood swings that do not meet the criteria for full
manic episode or full major depressive episode.
B. Substance-Induced Mood Disorder. The effects
of medication, drugs of abuse, or toxin exposure
should be excluded.
C. Mood Disorder Due to a General Medical
Condition. Manic symptoms can be associated
with AIDS, Cushing’s, hyperthyroidism, lupus,
multiple sclerosis, and brain tumors. Depressive
symptoms consistent with dysthymia may occur in
stroke, Parkinson’s disease, multiple sclerosis,
Huntington’s disease, vitamin B12 deficiency,
hypothyroidism, Cushing’s disease, pancreatic
carcinoma, and HIV.
VI.Treatment of Bipolar II Disorder. The treatment of
Bipolar II disorder includes a mood stabilizer and an
antidepressant if depression is present. Treatment is
similar to that of Bipolar I disorder, described above
(See Mood Stabilizers, page 110).

Cyclothymic Disorder
Cyclothymic disorder consists of chronic cyclical
episodes of mild depression and symptoms of mild
mania.

I. DSM-IV Diagnostic Criteria

A. Many periods of depression and hypomania,
occurring for at least two years. Depressive
episodes do not reach the severity of major
depression.
B. During the two-year period, the patient has not
been symptom-free for more than two months at a
time.
C. During the two-year period, no episodes of major
depression, mania or mixed states were present.
D. Symptoms are not accounted for by schizoaffective
disorder and do not coexist with schizophrenia,
schizophreniform disorder, delusional disorder, or
any other psychotic disorder.
E. Symptoms are not caused by substance use or a
general medical condition.
F. Symptoms cause significant distress or functional
impairment.
II. Clinical Features of Cyclothymic Disorder
A. Symptoms are similar to those of bipolar I disorder,
but they are of a lesser magnitude and cycles
occur at a faster rate.
B. Patients frequently have coexisting substance
abuse.
C. One-third of patients develop a severe mood
disorder (usually bipolar II).
D. Occupational and interpersonal impairment is
frequent and usually a consequence of hypomanic
states.
E. Cyclothymic disorder often coexists with borderline
personality disorder.
III. Epidemiology of Cyclothymic Disorder
A. The prevalence is 1%, but cyclothymic disorder
constitutes 5-10% of psychiatric outpatients.
B. The onset occurs between age 15 and 25, and
women are affected more than men by a ratio of
3:2.
 C. Thirty percent of patients have a family history of
bipolar disorder.
IV.Differential Diagnosis of Cyclothymic Disorder
A. Bipolar II Disorder. Patients with bipolar type II
disorder exhibit hypomania and episodes of major
depression.
B. Substance-Induced Mood Disorder/Mood
Disorder Due to a General Medical Condition.
Hypomanic symptoms can be associated with
AIDS, Cushing’s, hyperthyroidism, lupus, multiple
sclerosis, and brain tumors. Depressive symptoms
consistent with dysthymia may occur in stroke,
Parkinson’s disease, multiple sclerosis,
Huntington’s disease, vitamin B12 deficiency,
hypothyroidism, Cushing’s disease, pancreatic
carcinoma, and HIV.
C. Personality Disorders (antisocial, borderline,
histrionic, narcissistic) can be associated with
marked shifts in mood. Personality disorders may
coexist with cyclothymic disorder.
V. Treatment of Cyclothymic Disorder
A. Mood stabilizers are the treatment of choice, and
lithium is effective in 60% of patients. The clinical
use of mood stabilizers is similar to that of bipolar
disorder. (Also see Mood Stabilizers, page 110).
B. Depressive episodes must be treated cautiously
because of the risk of precipitating manic
symptoms with antidepressants (occurs in 50% of
patients) or increase the rate of cycling. The
serotonin-norepinephrine re-uptake inhibitors and
tricyclics may have greater risk. A conservative
approach would be to treat concurrently with an
antidepressant and a mood stabilizer.
C. Patients often require supportive therapy to
improve awareness of their illness and to deal with
the functional consequences of their behavior.

References
References, see page 120.

Anxiety Disorders
Generalized Anxiety Disorder
Generalized anxiety disorder (GAD) is the most common
of the anxiety disorders. It is characterized by unrealistic
or excessive anxiety and worry about two or more life
circumstances for at least six months.

I. DSM-IV Diagnostic Criteria for Generalized Anxiety

Disorder
A. Excessive anxiety or worry is present most days
during at least a six-month period and involves a
number of life events.
B. The anxiety is difficult to control.
C. At least three of the following:
1. Restlessness or feeling on edge.
2. Easy fatigability.
3. Difficulty concentrating.
4. Irritability.
5. Muscle tension.
6. Sleep disturbance.
D. The focus of anxiety is not anticipatory anxiety
about having a panic attack, as in panic disorder.
E. The anxiety or physical symptoms cause significant
distress or impairment in functioning.
F. Symptoms are not caused by substance use or a
medical condition, and symptoms are not related to
a mood or psychotic disorder.
II. Clinical Features of Generalized Anxiety Disorder
A. Other features often include insomnia, irritability,
trembling, muscle aches and soreness, muscle
twitches, clammy hands, dry mouth, and a height-
ened startle reflex. Patients may also report
palpitations, dizziness, difficulty breathing, urinary
frequency, dysphagia, light-headedness, abdomi-
nal pain, and diarrhea.
B. Patients often complain that they “can’t stop
worrying,” which may revolve around valid
concerns about money, jobs, marriage, health, and
the safety of children.
C. Chronic worry is a prominent feature of generalized
anxiety disorder, unlike the intermittent terror that
characterizes panic disorder.
D. Mood disorders, substance- and stress-related
disorders (headaches, dyspepsia) commonly
coexist with GAD. Up to one-fourth of GAD patients
develop panic disorder. Excessive worry and
somatic symptoms, including autonomic
hyperactivity and hypervigilance, occur most days.
E. About 30-50% of patients with anxiety disorders will
also meet criteria for major depressive disorder.
 Drugs and alcohol may cause anxiety or may be an
attempt at self-treatment. Substance abuse may
be a complication of GAD.
III. Epidemiology
A. Lifetime prevalence is 5%.
B. The female-to-male sex ratio for GAD is 2:1.
C. Most patients report excessive anxiety during
childhood or adolescence; however, onset after
age 20 may sometimes occur.
IV.Differential Diagnosis of Generalized Anxiety
Disorder
A. Substance-Induced Anxiety Disorder.
Substances such as caffeine, amphetamines, or
cocaine can cause anxiety symptoms. Alcohol or
benzodiazepine withdrawal can mimic symptoms of
GAD. These disorders should be excluded by
history and toxicology screen.
B. Panic Disorder, Obsessive-Compulsive
Disorder, Social Phobia, Hypochondriasis and
Anorexia Nervosa
1. Many psychiatric disorders present with marked
anxiety, and the diagnosis of GAD should be
made only if the anxiety is unrelated to the other
disorders.
2. For example, GAD should not be diagnosed in
panic disorder if the patient has excessive
anxiety about having a panic attack, or if an
anorexic patient has anxiety about weight gain.
C. Anxiety Disorder Due to a General Medical
Condition. Hyperthyroidism, cardiac arrhythmias,
pulmonary embolism, congestive heart failure, and
hypoglycemia, may produce significant anxiety and
should be ruled out as clinically indicated.
D. Mood and Psychotic Disorders
1. Excessive worry and anxiety occurs in many
mood and psychotic disorders.
2. If anxiety occurs only during the course of the
mood or psychotic disorder, then GAD cannot
be diagnosed.
V. Laboratory Evaluation of Anxiety
A. Serum glucose, calcium and phosphate levels,
electrocardiogram, and thyroid studies should be
included in the initial workup of all patients.
B. Other Studies. Urine drug screen and urinary
catecholamine levels may be required to exclude
specific disorders.
VI.Treatment of Generalized Anxiety Disorder
A. The combination of pharmacologic therapy and
psychotherapy is the most successful form of
treatment.
VII. Pharmacotherapy of Generalized Anxiety
Disorder
A. Antidepressants
1. SSRIs and Venlafaxine (Effexor and Effexor
XR) are first-line treatments for GAD. Effexor
XR can be started at 75 mg per day; however,
patients with severe anxiety or panic attacks
should begin at 37.5 mg per day. The dose
should then be titrated up to a maximum
dosage of 225 mg of Effexor XR per day.
2. The onset of action of antidepressants is much
slower than the benzodiazepines, but they have
no addictive potential and may be more effec-
tive. An antidepressant is the agent of choice
when depression coexists with anxiety.
3. The side-effect profile for GAD patients is
similar to that seen with depressive disorders.
4. Tricyclic antidepressants are also effective in
treating GAD, but adverse effects limit their use.
5. Buspirone (BuSpar)
a. Buspirone is an effective treatment for GAD.
Buspirone usually requires 3-6 weeks at a
dosage of 10-20 mg tid for efficacy. It lacks
sedative effects. Tolerance to the beneficial
effects of buspirone does not seem to
develop. There is no physiologic
dependence or withdrawal syndrome.
b. Combined benzodiazepine-buspirone
therapy may be used for generalized anxiety
disorder, with subsequent tapering of the
benzodiazepine after 2-4 weeks.
c. Patients who have been previously treated
with benzodiazepines or who have a history
of substance abuse have a decreased
response to buspirone.
d. Buspirone may have some antidepressant
effects.
B. Benzodiazepines
1. Benzodiazepines can almost always relieve
anxiety if given in adequate doses, and they
have no delayed onset of action.
2. Long-term use of benzodiazepines should be
reserved for patients who have failed to respond
to venlafaxine (Effexor), SSRIs, buspirone
(BuSpar) and other antidepressants, or who are
 intolerant to their side effects.
3. Benzodiazepines are very useful for treating
anxiety during the period in which it takes
buspirone or antidepressants to exert their
effects. Benzodiazepines should then be
tapered after several weeks.
4. Benzodiazepines have few side effects other
than sedation. Tolerance to their sedative
effects develops but not to their antianxiety
properties.
5. Since clonazepam (Klonopin) and diazepam
(Valium) have long half-lives, they are less likely
to result in interdose anxiety and are easier to
taper.
6. Drug dependency becomes a clinical issue if
the benzodiazepine is used regularly for more
than 2-3 weeks. A withdrawal syndrome occurs
in 70% of patients, characterized by intense
anxiety, tremulousness dysphoria, sleep and
perceptual disturbances and appetite
suppression. Slow tapering of benzodiazepines
is crucial (especially those with short half-lives).
C. Non-Drug Approaches to Anxiety
1. Patients should stop drinking coffee and other
caffeinated beverages, and avoid excessive
alcohol consumption.
2. Patients should get adequate sleep, with the
use of medication if necessary. Moderate
exercise each day may help reduce the intensity
of anxiety symptoms.
3. Psychotherapy
a. Cognitive behavioral therapy, with emphasis
on relaxation techniques and instruction on
misinterpretation of physiologic symptoms,
may improve functioning in mild cases.
b. Supportive or insight oriented psychotherapy
can be helpful in mild cases of anxiety.

Panic Disorder
Patients with panic disorder report discrete periods of
intense terror and fear of impending doom, which are
almost intolerable.

I. DSM-IV Criteria for Panic Disorder with

Agoraphobia
A. Both 1 and 2 are Required
1. Recurrent unexpected panic attacks occur,
during which four of the following symptoms
begin abruptly and reach a peak within 10
minutes in the presence of intense fear:
a. Palpitations, increased heart rate.
b. Sweating.
c. Trembling or shaking.
d. Sensation of shortness of breath.
e. Feeling of choking.
f. Chest pain or discomfort.
g. Nausea or abdominal distress.
h. Feeling dizzy, lightheaded or faint.
i. Derealization or depersonalization.
j. Fear of losing control or going crazy.
k. Fear of dying.
l. Paresthesias.
m. Chills or hot flushes.
2. At least one of the attacks has been followed by
one month of one of the following:
a. Persistent concern about having additional
attacks.
b. Worry about the implications of the attack,
such as fear of having a heart attack or going
crazy.
c. A significant change in behavior related to
the attacks.
B. The presence of agoraphobia has the following
three components:
1. Anxiety about being in places or situations
where escape might be difficult or
embarrassing, or in which help might not be
available.
2. Situations are avoided or endured with marked
distress, or these situations are endured with
anxiety about developing panic symptoms, or
these situations require the presence of a
companion.
3. The anxiety is not better accounted for by
another disorder, such as social phobia, where
phobic avoidance is only limited to social
situations.
C. Panic attacks are not due to the effects of a
substance or medical condition.
D. The panic attacks are not caused by another
mental disorder, such as panic on exposure to
social situations in social phobia, or panic in
 response to stimuli of a severe stressor, such as
with post-traumatic stress disorder.
II. DSM-IV Criteria for Panic Disorder without
Agoraphobia. The DSM-IV diagnostic criteria are the
same as panic disorder with agoraphobia, except
there are no symptoms of agoraphobia.
III. Clinical Features of Panic Disorder
A. Patients often believe that they have a serious
medical condition. Marked anxiety about having
future panic attacks (anticipatory anxiety) is
common.
B. In agoraphobia, the most common fears are of
being outside alone or of being in crowds or
traveling. The first panic attack often occurs without
an acute stressor or warning. Later in the disorder,
panic attacks may occur in relation to specific
situations, and phobic avoidance to these
situations can occur.
C. Major Depression occurs in over fifty percent of
patients. Agoraphobia may develop in patients with
simple panic attacks. Elevation of blood pressure
and tachycardia may occur during a panic attack.
IV.Epidemiology of Panic Disorder
A. The lifetime prevalence of panic disorder is
between 1.5% and 3.5%. The female-to-male ratio
is 3:1. Up to one-half of panic disorder patients
have agoraphobia.
B. Panic disorder usually develops in early adulthood
with a peak onset in the mid twenties. Onset after
age 45 years is unusual.
C. First-degree relatives have an eightfold increase in
panic disorder.
D. The course of the illness is often chronic, but
symptoms may wax and wane depending on the
presence of stressors. Fifty percent of panic
disorder patients are only mildly affected. Twenty
percent have marked symptomatology.
E. The suicide risk is markedly increased, especially
in untreated patients. Substance abuse, especially
of alcohol, may occur in up to 40% of patients.
V. Classification of Panic Disorder
A. Unexpected Panic Attacks. These panic attacks
occur spontaneously without any situational trigger.

B. Situationally Bound Panic Attacks. These panic

attacks occur immediately after exposure to the
feared stimulus, such as being in a high place or in
an elevator.
C. Situationally Predisposed Panic Attacks. These
panic attacks usually occur upon exposure to the
feared stimulus, but they do not necessarily occur
immediately after every exposure. For example, an
individual may have panic attacks in crowded
situations, but he may not have an attack in every
situation, or the attack may occur only after
spending a significant amount of time in a crowded
location.
VI.Differential Diagnosis of Panic Disorder
A. Generalized Anxiety Disorder. Anxiety is more
constant than in panic disorder. Panic disorder is
characterized by discrete episodes of severe
anxiety along with physiologic symptoms.
B. Substance-Induced Anxiety Disorder.
Amphetamines, cocaine or caffeine can mimic
panic attacks. Physiologic withdrawal from alcohol,
benzodiazepines or barbiturates can also
precipitate panic attacks.
C. Anxiety Due to a General Medical Condition.
Pheochromocytoma may mimic panic disorder and
is characterized by markedly elevated blood
pressure during the episodes of anxiety. It is
excluded by a 24-hour urine assay for
metanephrine or by serum catecholamines.
Cardiac arrhythmias, hyperthyroidism, pulmonary
embolism and hypoxia can present with symptoms
similar to panic attacks.
VII. Treatment of Panic Disorder
A. Mild cases of panic disorder can be effectively
treated with cognitive behavioral psychotherapy
with an emphasis on relaxation and instruction on
misinterpretation of physiologic symptoms.
B. Pharmacotherapy is indicated when patients have
marked distress from panic attacks or are
experiencing impairment in work or social
functioning.
1. Serotonin-specific reuptake inhibitors and
tricyclic antidepressants are most often used.
2. SSRIs are the first-line treatment for panic
disorder. Initiate treatment at lower doses than
used in depression because routine
antidepressant doses may actually increase
anxiety in panic disorder patients. For example,
5-10 mg of paroxetine (Paxil) or 12.5-25 mg of
sertraline (Zoloft) is used initially. The dose may
then be gradually increased up to 20-40 mg for
 paroxetine or 50 to 100 mg for sertraline.
Fluoxetine (Prozac) may exacerbate panic
symptoms unless begun at very low doses (2-5
mg). Venlafaxine, citalopram, and escitalopram
are also effective.
3. When using a tricyclic antidepressant, the initial
dose should also be low because of the
potential for exacerbating panic symptoms early
in treatment. Imipramine (Tofranil) is the best
studied agent, and it should be started at 10-25
mg per day, then increased slowly up to 100-
200 mg per day as tolerated.
4. Benzodiazepines may be used adjunctively with
TCAs or SSRIs during the first few weeks of
treatment. When a patient has failed other
agents, benzodiazepines are very effective.
Alprazolam (Xanax) should be given four times
a day to decrease interdose anxiety. The
average dose is 0.5 mg qid (2 mg/day). Some
patients may require up to 6 mg per day. A long-
acting agent such as clonazepam (Klonopin) is
also effective and causes less interdose anxiety
compared to alprazolam. Clonazepam can be
given less frequently than alprazolam.
5. Buspirone (BuSpar) is not effective for panic
disorder.
6. Monoamine oxidase inhibitors(MAOIs) may be
the most effective agents available for panic
disorder, but these agents are not often used
because of concern over hypertensive crisis.
7. Medication should be combined with cognitive-
behavioral therapy for optimal outcome.

Obsessive-Compulsive Disorder
(OCD)
I. DSM-IV Criteria for Obsessive-Compulsive
Disorder
A. Either Obsessions or Compulsions are present
1. Obsessions
a. Recurrent, persistent thoughts, impulses, or
images experienced as intrusive and causing
marked anxiety.
b. The thoughts, impulses, or images are not
limited to excessive worries about real
problems.
c. The person attempts to ignore or suppress
symptoms, or attempts to neutralize them
with some other thought or action.
d. The person recognizes the thoughts,
impulses or images as a product of his or her
own mind.
2. Compulsions
a. Repetitive behaviors or acts that the person
feels driven to perform in response to an
obsession.
b. These behaviors or mental acts are aimed at
preventing distress or preventing a specific
dreaded event, but they are not connected in
a realistic way to what they are attempting to
prevent, or they are clearly excessive.
3. The person has recognized that the obsessions
or compulsions are
excessive or unreasonable.
4. The obsessions or compulsions cause marked
distress, take more than a hour a day, or
significantly interfere with functioning.
5. If another psychiatric disorder is present, the
content of the symptoms is not restricted to the
disorder (eg, preoccupation with food in an
eating disorder.
6. The disturbance is not caused by substance
abuse or a medical condition.
7. Specify if the patient has poor insight into his
illness. Poor insight is present if, for most of the
current episode, the person does not recognize
the symptoms as excessive or unreasonable.
II. Clinical Features of Obsessive-Compulsive
Disorder
A. Compulsions often occupy a large portion of an
individuals day, leading to marked occupational
and social impairment.
B. Situations that provoke symptoms are often
avoided, such as when an individual with
obsessions of contamination avoids touching
anything that might be dirty.
C. Depression is common in patients with OCD.
Alcohol or sedative-hypnotic drug abuse is
common in patients with OCD because they
attempt to use the drug to reduce distress.
D. Washing and checking rituals are common in
children with OCD, and these children may not
consider their behavior to be unreasonable or
 excessive.
E. Patients are reluctant to discuss symptoms, leading
to an underdiagnosis of OCD.
III. Epidemiology of Obsessive-Compulsive Disorder
A. The lifetime prevalence of OCD is approximately
2.5%. There is no sex difference in prevalence, but
the age of onset is earlier in males.
B. The concordance rate for monozygotic twins is
markedly higher compared to dizygotic twins.
C. OCD usually begins in adolescence or early
adulthood, but it may occasionally begin in
childhood.
D. The onset is usually gradual and most patients
have a chronic disease course with waxing and
waning of symptoms in relation to life stressors.
E. Fifteen percent of patients have a chronic
debilitating course with marked impairment in
social and occupational functioning.
F. Up to 50% of patients with Tourette’s disorder have
coexisting OCD; however, only 5% of OCD patients
have Tourette’s disorder.
IV.Differential Diagnosis of Obsessive-Compulsive
Disorder
A. Substance-Induced Anxiety Disorder or Anxiety
Disorder Due to a Medical Condition.
Amphetamines, cocaine, caffeine and other
symptomatic agents may mimic the anxiety
symptoms of OCD. On rare occasions a brain
tumor or temporal lobe epilepsy can manifest with
OCD symptoms.
B. Major Depressive Disorder. Major depression
may be associated with severe obsessive
ruminations (eg, obsessive rumination about
finances or a relationship). These obsessive
thoughts are usually not associated with
compulsive behaviors and are accompanied by
other symptoms of depression.
C. Generalized Anxiety Disorder. In GAD, obsessive
worries are about real life situations; however, in
OCD, obsessions usually do not involve real life
situations.
D. Specific or Social Phobia, Body Dysmorphic
Disorder or Trichotillomania. Recurrent thoughts,
behaviors or impulses may occur in these
disorders. OCD should not be diagnosed if
symptoms are caused by another psychiatric
condition (eg, hair pulling in trichotillomania).
E. Schizophrenia. Patients with schizophrenia may
have obsessive thoughts or compulsive behaviors;
however, schizophrenia is associated with frank
hallucinations and delusions.
F. Obsessive-Compulsive Personality Disorder
(OCPD). Individuals with OCPD are preoccupied
with perfectionism, order, and control, and they do
not believe that their behavior is abnormal. They do
not exhibit obsessions or compulsions.
V. Treatment of Obsessive-Compulsive Disorder
A. Pharmacotherapy is almost always indicated.
B. Clomipramine (Anafranil), sertraline (Zoloft),
paroxetine (Paxil) fluoxetine (Prozac), citalopram
(Celexa), escitalopram (Lexapro) and fluvoxamine
(Luvox) are effective.
C. Standard antidepressant doses of clomipramine
are usually effective, but higher doses of SSRIs are
usually required, such as fluoxetine (Prozac) 60-80
mg, paroxetine (Paxil) 40-60 mg, or sertraline
(Zoloft) 200 mg.
D. Behavior therapy, such as cognitive-behavioral
therapy, thought stopping, desensitization or
flooding, may also be effective. A combination of
behavioral therapy and medication is most
effective.
E. It is rare for treatment to completely eliminate the
symptoms of OCD, but significant clinical
improvement in symptoms can occur, and the
patient’s functioning can be drastically enhanced.

Social Phobia
I. DSM-IV Diagnostic Criteria for Social Phobia (also
know as Social Anxiety Disorder)
1. A marked and persistent fear of social or
performance situations in which the person is
exposed to unfamiliar people or to scrutiny by
others. The individual often fears that he will act
in a way that will be humiliating or embarrassing.
2. Exposure to the feared situation almost
invariably provokes anxiety, which may take the
form of a panic attack.
3. The person recognizes that the fear is excessive
or unreasonable.
4. The feared situations are avoided or endured
with intense distress.
 5. The avoidance, anxious anticipation, or distress
in the feared situations interferes with normal
functioning or causes marked distress.
6. The duration of symptoms is at least six months.
7. The fear is not caused by a substance or
medical condition and is not caused by another
disorder.
8. If a medical condition or another mental disorder
is present, the fear is unrelated (eg, the fear is
not of trembling in a patient with Parkinson’s
disease).
9. Specify if the fear is generalized: The fear is
generalized if the patient fears most social
situations.
II. Clinical Features of Social Phobia
A. Patients often display hypersensitivity to criticism,
difficulty being assertive, low self-esteem, and
inadequate social skills.
B. Avoidance of speaking in front of groups may lead
to work or school difficulties. Most patients with
social phobia fear public speaking, while less than
half fear meeting new people.
C. Less common fears include fear of eating, drinking,
or writing in public, or of using a public restroom.
III. Epidemiology and Etiology of Social Phobia
A. Lifetime prevalence is 3-13%.
B. Social phobia is more frequent (up to tenfold) in
first-degree relatives of patients with generalized
social phobia.
C. Onset usually occurs in adolescence, with a
childhood history of shyness.
D. Social phobia is often a lifelong problem, but the
disorder may remit or improve in adulthood.
IV.Differential Diagnosis of Social Phobia
A. Substance-Induced Anxiety Disorder.
Substances such as caffeine, amphetamines,
cocaine, alcohol or benzodiazepines may cause a
withdrawal syndrome that can mimic symptoms of
social phobia
B. Obsessive-Compulsive Disorder, Specific
Phobia, Hypochondriasis, or Anorexia Nervosa.
Anxiety symptoms are common in depression and
the anxiety disorders. The diagnosis of social
phobia should be made only if the anxiety is
unrelated to another disorder. For example, social
phobia should not be diagnosed in panic disorder if
the patient has social restriction and excessive
anxiety about having an attack in public.
C. Anxiety Disorder Due to a General Medical
Condition. Hyperthyroidism (and other medical
conditions) may produce significant anxiety, and
should be ruled out.
D. Mood and Psychotic Disorders. Excessive social
worry and anxiety can occur in many mood and
psychotic disorders. If anxiety occurs only during
the course of the mood or psychotic disorder, then
social phobia should not be diagnosed.
V. Treatment of Social Phobia
A. SSRIs, such as paroxetine (Paxil) 20-40 mg/day or
sertraline (Zoloft) 50-100 mg/day, are first-line
medications for social phobia. Venlafaxine (Effexor
XR) 75-225mg/day may also be used.
Benzodiazepines, such as clonazepam (Klonopin)
0.5-2 mg per day, may be used if antidepressants
are ineffective.
B. Social phobia with performance anxiety (for specific
situations known to be anxiety provoking) responds
well to beta-blockers, such as propranolol. The
effective dosage can be very low, such as 10-20
mg qid. It may also be used on a prn basis; 20-40
mg given 30-60 minutes prior to the anxiety
provoking event.
C. Cognitive/behavioral therapies are effective and
should focus on cognitive retraining,
desensitization, and relaxation techniques.
Combined pharmacotherapy and cognitive or
behavioral therapies is the most effective
treatment.

Specific Phobia
I. DSM-IV Diagnostic Criteria
A. Marked and persistent fear that is excessive or
unreasonable, which is caused by the presence or
anticipation of a specific object or situation.
B. Exposure to the feared stimulus provokes an
immediate anxiety response, which may take the
form of a panic attack.
C. Recognition by the patient that the fear is
excessive or unreasonable.
D. The phobic situation is avoided or endured with
intense anxiety.
E. The avoidance, anxious anticipation, or distress in
 the feared situations interferes with functioning or
causes marked distress.
F. In individuals under age 18, the duration must be at
least six months.
G. Symptoms are not caused by another mental
disorder (eg, fear of dirt in someone with OCD).
H. Specify Types of Phobias
1. Animal (eg, dogs).
2. Natural Environmental (eg, heights, storms,
water).
3. Blood-injection injury.
4. Situational (eg, airplanes, elevators, enclosed
places).
5. Other (eg, situations that may lead to choking,
vomiting).
II. Clinical Features of Specific Phobia
A. Specific phobias may result in a significant
restriction of life-activities or occupation. Vasovagal
fainting is seen in 75% of patients with blood-
injection injury phobias.
B. Specific phobias often occur along with other
anxiety disorders.
C. Many phobias do not come to clinical attention
because they do not interfere with functioning.
D. Fear of animals and other objects is common in
childhood, and specific phobia is not diagnosed
unless the fear leads to significant impairment,
such as unwillingness to go to school.
E. Most childhood phobias are self-limited and do not
require treatment. Phobias that continue into
adulthood rarely remit.
III. Epidemiology of Specific Phobia
A. The lifetime prevalence of phobias is 10%. Most do
not cause clinically significant impairment or
distress.
B. Age of onset is variable, and females with the
disorder far outnumber males.
IV.Differential Diagnosis of Specific Phobia
A. Substance-Induced Anxiety Disorder.
Substances such as caffeine, amphetamines and
cocaine can mimic phobic symptoms. Alcohol or
benzodiazepine withdrawal can also mimic phobic
symptoms.
B. Panic Disorder, Obsessive-Compulsive
Disorder, Social Phobia, Hypochondriasis or
Anorexia Nervosa. Many psychiatric disorders
present with marked anxiety, and the diagnosis of
specific phobia should be made only if the anxiety
is unrelated to another disorder. For example,
phobias regarding eating or weight gain are not
diagnosed if they are secondary to an underlying
eating disorder.
C. Anxiety Disorder Due to a General Medical
Condition. Hyperthyroidism and other medical
conditions may produce significant anxiety.
D. Mood and Psychotic Disorders. Excessive worry
and anxiety occurs in many mood and psychotic
disorders. If anxiety occurs only during the course
of the mood or psychotic disorder, then specific
phobia should not be diagnosed.
V. Treatment of Specific Phobia
A. The primary treatment is behavioral therapy. A
commonly used technique is systemic
desensitization, consisting of gradually increasing
exposure to the feared situation, combined with a
relaxation technique such as deep breathing.
B. Beta-blockers may also be useful prior to
confronting the specific feared situation.

Post-Traumatic Stress Disorder

I. DSM-IV Diagnostic Criteria for Post-Traumatic
Stress Disorder
A. Post-traumatic stress disorder (PTSD) occurs after
an individual has been exposed to a traumatic
event that is associated with intense fear or horror.
B. The patient persistently reexperiences the event
through intrusive recollection or nightmares,
reliving of the experience (flashbacks), or intense
distress when exposed to reminders of the event.
C. The patient may have feelings of detachment
(emotional numbing), anhedonia, amnesia,
restricted affect, or active avoidance of thoughts or
activities that may be reminders of the trauma
(three required).
D. A general state of increased arousal persists after
the traumatic event, which is characterized by poor
concentration, hypervigilance, exaggerated startle
response, insomnia, or irritability (two required).
E. Symptoms have been present for at least one
month.
F. Symptoms cause significant distress or impaired
occupational or social functioning.
II. Clinical Features of Post-Traumatic Stress
Disorder
A. Survivor guilt (guilt over surviving when others
have died) may be experienced if the trauma was
associated with a loss of life.
B. Personality change, poor impulse control,
aggression, dissociative symptoms, and perceptual
disturbances may occur.
C. The risk of depression, substance abuse, other
anxiety disorders, somatization disorder, and
suicide are increased.
III. Epidemiology of Post-Traumatic Stress Disorder
A. The lifetime prevalence of PTSD is 8% and is
highest in young adults.
B. The prevalence in combat soldiers and assault
victims is 60%.
C. Individuals with a personal history of maladaptive
responses to stress may be predisposed to
developing PTSD.
IV.Classification of Post-Traumatic Stress Disorder
A. Acute. Symptoms have been present for less than
three months.
B. Chronic. Symptoms have been present for greater
than three months.
C. With Delayed Onset. Symptoms begin six months
after the stressor.
V. Differential Diagnosis of Post-Traumatic Stress
Disorder
A. Depression is also associated with insomnia,
anhedonia, poor concentration, and feelings of
detachment. A stressful event may be associated
with the onset of depression. Depression is not
commonly associated with nightmares or
flashbacks of a traumatic event.
B. Obsessive-Compulsive Disorder. OCD is
associated with recurrent intrusive ideas. However,
these ideas lack a relationship to a specific
traumatic event, and the ideas are not usually
recollections of past events.
C. Malingering. PTSD may be an illness for which
monetary compensation is given. The presence of
a primary financial gain for which patients may
fabricate or exaggerate symptoms should be
considered during evaluation.
D. Anxiety Disorders. Other anxiety disorders can
cause symptoms of increased arousal, numbing,
and avoidance. Symptoms, however, often were
present before the traumatic event.
E. Borderline Personality Disorder can be
associated with anhedonia, poor concentration,
past history of emotional trauma and dissociative
states similar to flashbacks. Other features of BPD
such as avoidance of abandonment, identity
disturbance, and impulsivity distinguishes BPD
from PTSD.
VI.Treatment of Post-Traumatic Stress Disorder
A. Sertraline (Zoloft) and paroxetine (Paxil) have
demonstrated efficacy for all the symptom clusters
of PTSD. Other SSRIs are also likely to be
effective. Treatment at higher doses than are used
for depression may be required. Older
antidepressants (imipramine, amitriptyline, and
monoamine oxidase inhibitors [MAOIs]) are
moderately effective, especially for symptoms of
increased arousal, intrusive thoughts, and
coexisting depression.
B. Propranolol, lithium, anticonvulsants, and
buspirone may be effective and should be
considered if there is no response to
antidepressants. Benzodiazepines are not effective
for PTSD, except during the early, acute phase of
the illness.
C. Psychotherapy, behavioral therapy, support
groups, and family therapy are effective adjuncts to
pharmacological treatment.

Acute Stress Disorder

Acute stress disorder may occur as an acute reaction
following exposure to extreme stress.

I. DSM-IV Criteria for Acute Stress Disorder.

A. Symptoms described below occur after an
individual has been exposed to a traumatic event
that is outside the realm of normal human
experience (combat, natural disaster, physical
assault, accident).
B. The patient persistently reexperiences the event
through intrusive recollection or nightmares,
reliving of the experience (flashbacks), or intense
distress when exposed to reminders of the event.
C. Persistent avoidance of the traumatic event and
emotional numbing (feeling of detachment from
 others) may be present. The patient may have
feelings of detachment, anhedonia, amnesia,
restricted affect, or active avoidance of thoughts or
activities that may be reminders of the trauma
(three required).
D. A general state of increased arousal persists after
the traumatic event, which is characterized by poor
concentration, hypervigilance, exaggerated startle
response, insomnia or irritability (two required).
E. Additional findings in acute stress disorder may
include the following:
1. Symptoms occur within one month of a stressor
and last between two days and four weeks.
2. The individual has three or more of the following
dissociative symptoms:
a. Subjective sense of numbing, detachment or
absence of emotional responsiveness.
b. Reduction in awareness of surroundings.
c. Derealization.
d. Depersonalization.
e. Dissociative amnesia.
II. Treatment of Acute Stress Disorder
A. The presence of acute stress disorder may
precede PTSD. The clinical approach to acute
stress disorder is similar to PTSD.
B. Treatment of acute stress disorder consists of
supportive psychotherapy.
C. Sedative hypnotics are indicated for short-term
treatment of insomnia and symptoms of increased
arousal. Antidepressant medications are indicated
if these agents are ineffective.

References
References, see page 120.

Personality Disorders
I. General Characteristics of Personality Disorders
A. Personality traits consist of enduring patterns of
perceiving, relating to, and thinking about the
environment, other people and oneself.
B. A personality disorder is diagnosed when
personality traits become inflexible, pervasive and
maladaptive to the point where they cause
significant social or occupational dysfunction or
subjective distress. Patients usually have little or no
insight into their disorder.
C. Personality patterns must be stable and date back
to adolescence or early adulthood. Therefore,
personality disorders are not generally diagnosed
in children.
D. Patterns of behavior and perception cannot be
caused by stress, another mental disorder, drug or
medication effect, or a medical condition.

Cluster A Personality Disorders

Paranoid, schizotypal and schizoid personality disorders
are referred to as cluster A personality disorders.
Patients with these disorders have a preference for
social isolation. There is also an increased incidence of
schizophrenia in first-degree relatives compared to the
general population. Patients with cluster A personality
disorders often develop schizophrenia. They are
considered part of the schizophrenia-spectrum disorders,
possibly milder variants of schizophrenia.

Paranoid Personality Disorder

I. DSM-IV Diagnostic Criteria of Paranoid Personality
Disorder
A. A pervasive distrust and suspiciousness of others
is present without justification, beginning by early
adulthood, and is manifested by at least four of the
following:
1. The patient suspects others are exploiting,
harming, or deceiving him.
2. The patient doubts the loyalty or trustworthiness
of others.
3. The patient fears that information given to others
will be used maliciously against him.
4. Benign remarks by others or benign events are
interpreted as having demeaning or threatening
meanings.
5. The patient persistently bears grudges.
6. The patient perceives attacks that are not
apparent to others, and is quick to react angrily or
to counterattack.
7. The patient repeatedly questions the fidelity of his
spouse or sexual partner.
II. Clinical Features of Paranoid Personality Disorder
A. The patient is often hypervigilant and constantly
looking for proof to support his paranoia. Patients
are often argumentative and hostile.
B. Patients have a high need for control and
autonomy in relationships to avoid betrayal and the
need to trust others. Pathological jealousy is
common.
C. Patients are quick to counterattack and are
frequently involved in legal disputes. These
patients rarely seek treatment.
III. Epidemiology of Paranoid Personality Disorder
A. The disorder is more common in first-degree
relatives of schizophrenics compared to the
general population.
B. Patients with the disorder may develop
schizophrenia.
C. The disorder is more common in men than women.
IV.Differential Diagnosis of Paranoid Personality
Disorder
A. Delusional Disorder. Fixed delusions are not
seen in personality disorders.
B. Paranoid Schizophrenia. Hallucinations and
formal thought disorder are not seen in personality
disorder.
C. Personality Change Due to a General Medical
Condition and Substance-Related Disorder.
Acute symptoms are temporally related to a
medication, drugs or a medical condition. The
longstanding patterns of behavior required for a
personality disorder are not present.
V. Treatment of Paranoid Personality Disorder
A. Psychotherapy is the treatment of choice for PPD,
but establishing and maintaining the trust of
patients may be difficult because these patients
have great difficulty tolerating intimacy.
B. Symptoms of anxiety and agitation may be severe
enough to warrant treatment with antianxiety
agents.
C. Low doses of antipsychotics are useful for
delusional accusations and agitation.

Schizoid Personality Disorder

I. DSM-IV Diagnostic Criteria for Schizoid
Personality Disorder
A. A pervasive pattern of social detachment with
restricted affect, beginning by early adulthood and
indicated by at least four of the following:
1. The patient neither desires nor enjoys close
relationships, including family relationships.
2. The patient chooses solitary activities.
3. The patient has little interest in having sexual
experiences.
4. The patient takes pleasure in few activities.
5. The patient has no close friends or confidants
except first-degree relatives.
6. The patient is indifferent to the praise or criticism
of others.
7. The patient displays emotional detachment or
diminished affective responsiveness.
II. Clinical Features of Schizoid Personality Disorder
A. The patient often appears cold and aloof, and is
uninvolved in the everyday concerns of others.
B. Patients with SPD are often emotionally blunted,
and these patients generally do not marry unless
pursued aggressively by another person.
C. These patients are able to work if the job allows for
social isolation.
III. Epidemiology of Schizoid Personality Disorder
A. Schizoid Personality Disorder is more common in
first-degree relatives of schizophrenics compared
to the general public.
B. Patients with Schizoid Personality Disorder may
develop schizophrenia.
C. Schizoid Personality Disorder is a rare disorder,
which is thought to be more common in men than
women.
IV.Differential Diagnosis of Schizoid Personality
Disorder
A. Schizophrenia. Hallucinations and formal thought
disorder are not seen in personality disorders.
Patients with schizoid personality disorder may
have good work histories, whereas schizophrenic
patients usually have poor work histories.
B. Schizotypal Personality Disorder. Eccentricities
and oddities of perception, behavior and speech
are not seen in schizoid personality disorder.
C. Avoidant Personality Disorder. Social isolation is
subjectively unpleasant for avoidant patients.
Unlike schizoid patients, avoidant patients are
hypersensitive to the thoughts and feelings of
others.
 D. Paranoid Personality Disorder. Paranoid patients
are able to express strong emotion when they feel
persecuted. Schizoid patients are not able to
express strong emotion.
E. Personality Change Due to a General Medical
Condition and Substance-Related Disorder.
Acute symptoms are temporally related to a
medication, drugs or a medical condition. The
longstanding patterns of behavior required for a
personality disorder are not present.
V. Treatment of Schizoid Personality Disorder
A. Individual psychotherapy is the treatment of choice.
Group therapy is not recommended because other
patients will find the patient’s silence difficult to
tolerate.
B. The use of antidepressants, antipsychotics and
psychostimulants has been described without
consistent results.

Schizotypal Personality Disorder

I. DSM-IV Diagnostic Criteria
A. A pervasive pattern of discomfort with and reduced
capacity for close relationships as well as
perceptual distortions and eccentricities of
behavior, beginning by early adulthood. At least
five of the following should be present:
1. Ideas of reference: interpreting unrelated events
as having direct reference to the patient (eg,
belief that a television program is really about
him).
2. Odd beliefs or magical thinking inconsistent with
cultural norms (eg, superstitiousness, belief in
clairvoyance, telepathy or a “sixth sense”).
3. Unusual perceptual experiences, including bodily
illusions.
4. Odd thinking and speech (eg, circumstantial,
metaphorical or stereotyped thinking).
5. Suspiciousness or paranoid ideation.
6. Inappropriate or constricted affect.
7. Behavior or appearance that is odd, eccentric or
peculiar.
8. Lack of close friends other than first-degree
relatives.
9. Excessive social anxiety that does not diminish
with familiarity.
II. Clinical Features of Schizotypal Personality
Disorder
A. These patients often display peculiarities in
thinking, behavior and communication.
B. Discomfort in social situations, and inappropriate
behavior may occur.
C. Magical thinking, belief in “extra sensory
perception,” illusions and derealization are
common.
D. Repeated exposure will not decrease social anxiety
since it is based on paranoid concerns and not on
self-consciousness.
E. The patient may have a vivid fantasy life with
imaginary relationships.
F. Speech may be idiosyncratic, such as the use of
unusual terminology.
G. These patients may seek treatment for anxiety or
depression.
III. Epidemiology of Schizotypal Personality Disorder
A. This disorder is more common in first-degree
relatives of schizophrenics compared to the
general population.
B. Patients with schizotypal personality disorder may
develop schizophrenia.
C. The prevalence is approximately 3% in the general
population.
IV.Differential Diagnosis of Schizotypal Personality
Disorder
A. Schizoid and Avoidant Personality Disorder.
Schizoid and avoidant patients will not display the
oddities of behavior, perception, and
communication of schizotypal patients.
B. Schizophrenia. No formal thought disorder is
present in personality disorders. When psychosis is
present in schizotypal patients, it is of brief
duration.
C. Paranoid Personality Disorder. Patients with
paranoid personality disorder will not display the
oddities of behavior, perception and
communication of schizotypal patients. Unlike
schizotypals, paranoid patients can be very
verbally aggressive and do not avoid conflict.
D. Personality Change Due to a General Medical
Condition and Substance-Related Disorder.
Acute symptoms are temporally related to a
medication, drugs or a medical condition. The
longstanding patterns of behavior required for a
 personality disorder are not present.
V. Treatment of Schizotypal Personality Disorder
A. Psychotherapy is the treatment of choice for
schizotypal personality disorder. Antipsychotics
may be helpful in dealing with low-grade psychotic
symptoms or paranoid delusions.
B. Antidepressants may be useful if the patient also
meets criteria for a mood disorder.

Cluster B Personality Disorders

Antisocial, borderline, histrionic and narcissistic
personality disorders are referred to as cluster B
personality disorders. These disorders are characterized
by dramatic or irrational behavior. These patients tend to
be very disruptive in clinical settings.

Antisocial Personality Disorder

I. DSM-IV Diagnostic Criteria for Antisocial
Personality Disorder
A. Since age 15 years, the patient has exhibited
disregard for and violation of the rights of others,
indicated by at least three of the following:
1. Failure to conform to social norms by repeatedly
engaging in unlawful activity.
2. Deceitfulness: repeated lying or “conning” others
for profit or pleasure.
3. Impulsivity or failure to plan ahead.
4. Irritability and aggressiveness, such as repeated
physical fighting or assaults.
5. Reckless disregard for the safety of self or others.
6. Consistent irresponsibility: repeated failure to
sustain consistent work or honor financial
obligations.
7. Lack of remorse for any of the above behavior.
B. A history of some symptoms of conduct disorder
before age 15 years as indicated by:
1. Aggression to people and animals.
2. Destruction of property.
3. Deceitfulness or theft.
4. Serious violation of rules.
II. Clinical Features of Antisocial Personality
Disorder
A. Interactions with others are typically exploitative or
abusive.
B. Lying, stealing, fighting, fraud, physical abuse,
substance abuse, and drunk driving are common.
C. Patients may be arrogant, but they are also
capable of great superficial charm.
D. These patients do not have a capacity for empathy.
III. Epidemiology of Antisocial Personality Disorder
A. The male-to-female ratio is 3:1.
B. APD is more common in first-degree relatives of
those with the disorder.
IV.Differential Diagnosis of Antisocial Personality
Disorder
A. Adult Antisocial Behavior. This diagnosis is
limited to the presence of illegal behavior only.
Patients with adult antisocial behavior do not show
the pervasive, long-term patterns required for a
personality disorder.
B. Substance-Related Disorder. Substance abuse
is common in antisocial personality disorder, and
crimes may be committed to obtain drugs or to
obtain money for drugs. Many patients will meet
criteria for both diagnoses.
C. Narcissistic Personality Disorder. Narcissistic
patients also lack empathy and are exploitative, but
they are not as aggressive or deceitful as antisocial
patients.
D. Borderline Personality Disorder. These patients
are also impulsive and manipulative, but they are
more emotionally unstable and they are less
aggressive. The manipulativeness of borderline
patients is aimed at getting emotional gratification
rather than aimed at financial motivations.
V. Treatment of Antisocial Personality Disorder
A. These patients will try to destroy or avoid the
therapeutic relationship. Inpatient self-help groups
are the most useful treatment because the patient
is not allowed to leave, and because enhanced
peer interaction minimizes authority issues.
B. Psychotropic medication is used in patients whose
symptoms interfere with functioning or who meet
criteria for another psychiatric disorder.
Anticonvulsants, lithium, and beta-blockers have
been used for impulse control problems, including
rage reactions. Antidepressants can be helpful if
depression or an anxiety disorder is present.
Borderline Personality Disorder
I. DSM-IV Diagnostic Criteria for Borderline
Personality Disorder
A pervasive pattern of unstable interpersonal
relationships, unstable self-image, unstable affects,
and poor impulse control, beginning by early
adulthood, and indicated by at least five of the
following:
1. Frantic efforts to avoid real or imagined
abandonment.
2. Unstable and intense interpersonal
relationships, alternating between extremes of
idealization and devaluation.
3. Identity disturbance: unstable self-image or
sense of self.
4. Impulsivity in at least two areas that are
potentially self-damaging (eg, spending,
promiscuity, substance abuse, reckless driving,
binge eating).
5. Recurrent suicidal behavior, gestures or
threats; or self-mutilating behavior.
6. Affective instability (eg, sudden intense
dysphoria, irritability or anxiety of short
duration).
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger or difficulty
controlling anger.
9. Transient, stress-related paranoid ideation, or
severe dissociative symptoms.
II. Clinical Features of Borderline Personality
Disorder
A. The clinical presentation of BPD is highly variable.
Chronic dysphoria is common, and desperate
dependence on others is caused by inability to
tolerate being alone.
B. Chaotic interpersonal relationships are
characteristic, and self-destructive or self-
mutilatory behavior is common.
C. A childhood history of abuse or parental neglect is
common.
III. Epidemiology of Borderline Personality Disorder
A. The female-to-male ratio is 2:1. The disorder is
five times more common in first-degree relatives.
B. The prevalence is 1-2%, but the disorder occurs in
30-60% of psychiatric patients.
IV. Differential Diagnosis of Borderline Personality
Disorder
A. Adolescence. Normal adolescence with identity
disturbance and emotional lability shares many of
the same characteristics of BPD; however, the
longstanding pervasive pattern of behavior
required for a personality disorder is not present.
B. Histrionic Personality Disorder. These patients
are also manipulative and attention seeking, but
they do not display self-destructiveness and rage.
Psychosis and dissociation are not typically seen
in histrionic patients.
C. Dependent Personality Disorder. When faced
with abandonment, dependent patients will
increase their submissive behavior rather than
display rage as do borderline patients.
D. Personality Change Due to a General Medical
Condition and Substance-Related Disorder.
Acute symptoms are temporally related to
medications, drugs, or a medical condition.
V. Treatment of Borderline Personality Disorder
A. Psychotherapy is the treatment of choice. Patients
frequently try to recreate their personal chaos in
treatment by displaying acting-out behavior,
resistance to treatment, lability of mood and
affect, and regression.
B. Suicide threats and attempts are common.
C. Pharmacotherapy is frequently used for coexisting
mood disorders, eating disorders, and anxiety
disorders. Valproate (Depakote) or SSRIs may be
helpful for impulsive-aggressive behavior.

Histrionic Personality Disorder

I. DSM-IV Diagnostic Criteria
A. A pervasive pattern of excessive emotionality and
attention seeking, beginning by early adulthood,
as indicated by five or more of the following:
1. The patient is not comfortable unless he is the
center of attention.
2. The patient is often inappropriately sexually
seductive or provocative with others.
3. Rapidly shifting and shallow expression of
emotions are present.
4. The patient consistently uses physical
appearance to attract attention.
 5. Speech is excessively impressionistic and
lacking in detail.
6. Dramatic, theatrical, and exaggerated
expression of emotion is used.
7. The patient is easily influenced by others or by
circumstances.
8. Relationships are considered to be more
intimate than they are in reality.
II. Clinical Features of Histrionic Personality
Disorder
A. The patient is bored with routine and dislikes
delays in gratification.
B. The patient begins projects, but does not finish
them (including relationships).
C. Dramatic emotional “performances” of the patient
appear to lack sincerity.
D. These patients often attempt to control
relationships with seduction, manipulation, or
dependency.
E. The patient may resort to suicidal gestures and
threats to get attention.
III. Epidemiology of Histrionic Personality Disorder
A. The prevalence of HPD is 2-3%.
B. Histrionic personality disorder is much more
common in women than men.
C. These patients have higher rates of depression,
somatization and conversion disorder compared
to the general population.
IV. Differential Diagnosis of Histrionic Personality
Disorder
A. Borderline Personality Disorder
1. While patients with Borderline Personality can
also be sensation-seeking, impulsive,
superficially charming, and manipulative, they
also have identity disturbance, transient
psychosis, and dissociation, which are not
seen in histrionic patients.
2. Some patients meet criteria for both BPD and
HPD.
B. Antisocial Personality Disorder
1. Antisocial patients are also sensation-seeking,
impulsive, superficially charming, and
manipulative.
2. Histrionic patients are dramatic and theatrical
but typically lack histories of antisocial
behavior.
C. Narcissistic Personality Disorder
1. Narcissists also seek constant attention, but it
must be positive in order to confirm grandiosity
and superiority.
2. Histrionics are less selective and will readily
appear weak and dependent in order to get
attention.
D. Personality Change Due to a General Medical
Condition and Substance-Related Disorder.
Acute symptoms are temporally related to
medication, drugs, or a medical condition.
V. Treatment of Histrionic Personality Disorder
A. Insight-oriented psychotherapy is the treatment of
choice. Keeping patients in therapy can be
challenging since these patients dislike routine.
B. Antidepressants are used if depression is also
present.

Narcissistic Personality Disorder

I. DSM-IV Diagnostic Criteria
A. A pervasive pattern of grandiosity (in fantasy or
behavior), need for admiration, and lack of
empathy. The disorder begins by early adulthood
and is indicated by at least five of the following:
1. An exaggerated sense of self-importance.
2. Preoccupation with fantasies of unlimited
success, power, brilliance, beauty, or ideal
love.
3. Believes he is “special” and can only be
understood by, or should associate with, other
special or high-status people (or institutions).
4. Requires excessive admiration.
5. Has a sense of entitlement.
6. Takes advantage of others to achieve his own
ends.
7. Lacks empathy.
8. The patient is often envious of others or
believes that others are envious of him.
9. Shows arrogant, haughty behavior or attitudes.
II. Clinical Features of Narcissistic Personality
Disorder
A. Patients with narcissistic personality disorder
exaggerate their achievements and talents, and
they are surprised when they do not receive the
recognition they expect.
B. Their inflated sense of self results in a devaluation
 of others and their accomplishments. Narcissistic
patients only pursue relationships that will benefit
them in some way.
C. These patients feel very entitled, expecting others
to meet their needs immediately, and they can
become quite indignant if this does not happen.
These patients are self-absorbed and unable to
respond to the needs of others. Any perception of
criticism is poorly tolerated, and these patients
can react with rage.
D. These patients are very prone to envy anyone
who possesses knowledge, skill or belongings
that they do not possess. Much of narcissistic
behavior serves as a defense against very poor
self-esteem.
III. Epidemiology of Narcissistic Personality Disorder
A. The prevalence of NPD is less than 1% in the
general population and up to 16% in clinical
populations.
B. The disorder is more common in men than
women. Studies have shown a steady increase in
the incidence of narcissistic personality disorder.
IV. Differential Diagnosis of Narcissistic Personality
Disorder
A. Histrionic Personality Disorder. Histrionic
patients are also attention seeking, but the
attention they seek does not need to be admiring.
They are more highly emotional and seductive
compared to patients with NPD.
B. Borderline Personality Disorder. These patients
also tend to idealize and devalue others, but
narcissistic patients lack the unstable identity,
self-destructive behavior, and abandonment fears
that characterize borderline patients.
C. Antisocial Personality Disorder. Interpersonal
exploitation, superficial charm, and lack of
empathy can be seen in both antisocial
personality disorder and narcissistic personality
disorder. However, antisocial patients do not
require constant admiration nor do they display
the envy seen in narcissistic patients.
D. Personality Change Due to a General Medical
Condition and Substance-Related Disorder. All
symptoms are temporally related to medication,
drugs or a medical condition.
V. Treatment of Narcissistic Personality Disorder
A. Psychotherapy is the treatment of choice, but the
therapeutic relationship can be difficult since envy
often becomes an issue.
B. Coexisting substance abuse may complicate
treatment. Depression frequently coexists with
NPD; therefore, antidepressants are useful for
adjunctive therapy.

Cluster C Personality Disorders

Avoidant, dependent and obsessive-compulsive
personality disorders are referred to as cluster C
personality disorders. These patients tend to be anxious
and their personality pathology is a maladaptive attempt
to control anxiety.

Avoidant Personality Disorder

I. DSM-IV Diagnostic Criteria
A. A pervasive pattern of social inhibition, feelings of
inadequacy and hypersensitivity, beginning by
early adulthood, and indicated by at least four of
the following:
1. The patient avoids occupational activities with
significant interpersonal contact due to fear of
criticism, disapproval or rejection.
2. Unwilling to get involved with people unless
certain of being liked.
3. Restrained in intimate relationships due to fear
of being shamed or ridiculed.
4. Preoccupied with being criticized or rejected in
social situations.
5. Inhibited in new interpersonal situations due to
feelings of inadequacy.
6. The patient views himself as socially inept,
unappealing or inferior to others.
7. Reluctance to take personal risks or to
engage in new activities because they may be
embarrassing.
II. Clinical Features of Avoidant Personality Disorder
A. The patient is usually shy and quiet and prefers to
be alone. The patient usually anticipates
unwarranted rejection before it happens.
B. Opportunities to supervise others at work are
usually avoided by the patient. These patients are
often devastated by minor comments they
 perceive to be critical.
C. Despite self-imposed restrictions, avoidant
personality disorder patients usually long to be
accepted and be more social.
III. Epidemiology of Avoidant Personality Disorder
A. The male-to-female ratio is 1:1.
B. Although adults with avoidant personality disorder
were frequently shy as children, childhood
shyness is not a predisposing factor.
IV. Differential Diagnosis of Avoidant Personality
Disorder
A. Social Phobia, Generalized Type shares many
features of avoidant personality disorder. Patients
may meet criteria for both disorders. The two
disorders may only be differentiated by a life-long
pattern of avoidance seen in patients with
avoidant personality disorder.
B. Dependent Personality Disorder. These
patients are also hypersensitive to criticism and
crave acceptance, but they will risk humiliation
and rejection in order to get their dependent
needs met. Patients may meet the criteria for both
disorders.
C. Schizoid Personality Disorder. These patients
also avoid interactions with others and are
anxious in social settings; however, schizoid
patients do not fear criticism and rejection.
Avoidant patients recognize that social isolation is
abnormal.
D. Panic Disorder with Agoraphobia. In patients
with panic disorder with agoraphobia, avoidance
occurs after the panic attack has begun, and the
avoidance is aimed at preventing another panic
attack from occurring.
V. Treatment of Avoidant Personality Disorder
A. Individual psychotherapy, group psychotherapy
and behavioral techniques may all be useful.
Group therapy may assist in dealing with social
anxiety. Behavioral techniques, such as
assertiveness training and systematic
desensitization, may help the patient to overcome
anxiety and shyness.
B. Beta-blockers can be useful for situational
anxiety.
C. Since many of these patients will meet criteria for
Social Phobia (generalized), a trial of SSRI
medication may prove beneficial. Patients are
prone to other mood and anxiety disorders, and
these disorders should be treated with
antidepressants or anxiolytics.

Dependent Personality Disorder

I. DSM-IV Diagnostic Criteria
A. A pervasive and excessive need to be cared for.
This need leads to submissive, clinging behavior,
and fears of separation beginning by early
adulthood and indicated by at least five of the
following:
1. Difficulty making everyday decisions without
excessive advice and reassurance.
2. Needs others to assume responsibility for
major areas of his life.
3. Difficulty expressing disagreement with others
and unrealistically fears loss of support or
approval if he disagrees.
4. Difficulty initiating projects or doing things on
his or her own because of a lack of self-
confidence in judgment or abilities.
5. Goes to excessive lengths to obtain
nurturance and support, to the point of
volunteering to do things that are unpleasant.
6. Uncomfortable or helpless when alone due to
exaggerated fears of being unable to care for
himself.
7. Urgently seeks another source of care and
support when a close relationship ends.
8. Unrealistically preoccupied with fears of being
left to take care of himself.
II. Clinical Features of Dependent Personality
Disorder
A. Patients will endure great discomfort in order to
perpetuate the caretaking relationship. Social
interaction is usually limited to the caretaker
network.
B. These patients may function at work if no initiative
is required.
III. Epidemiology of Dependent Personality Disorder
A. Women are affected slightly more than men.
B. Childhood illness or separation anxiety disorder of
childhood predispose patients to dependent
personality disorder.
IV. Differential Diagnosis of Dependent Personality
Disorder
A. Avoidant Personality Disorder. Avoidant
patients are more focused on avoiding shame and
rejection rather than getting needs met. Some
patients may meet criteria for both disorders.
B. Borderline Personality Disorder. Borderline
patients react with rage and emptiness when
feeling abandoned. Dependent patients react with
more submissive behavior when feeling
abandoned.
C. Histrionic Personality Disorder. These patients
are also needy and clinging, and they have a
strong desire for approval, but these patients
actively pursue almost any kind of attention. They
tend to be very flamboyant, unlike dependent
patients.
D. Personality Change Due to a General Medical
Condition and Substance-Related Disorder.
Acute symptoms are temporally related to a
medication, drugs or a medical condition.
V. Treatment of Dependent Personality Disorder
A. Insight-oriented psychotherapy, group, and
behavioral therapies, such as assertiveness and
social skills training, have all been used with
success. Family therapy may also be helpful in
supporting new needs of the dependent patient in
treatment.
B. Dependent patients are at increased risk for mood
disorders and anxiety disorders. Appropriate
pharmacological interventions may be used if the
patient has these disorders.

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

References
References, see page 120.

Somatoform and
Factitious Disorders

Somatization Disorder
I. DSM-IV Criteria
A. Many physical complaints, resulting in treatment
being sought or significant functional impairment.
Onset is before the age of 30.
B. Physical Complaints
1. History of pain related to at least four sites or
functions.
2. Two GI symptoms.
3. One sexual symptom.
4. One symptom suggestive of a neurological
condition (pseudoneurological).
C. Symptoms cannot be explained by organic etiology
or symptoms are in excess of what is expected
from the medical evaluation.
D. Symptoms are not intentionally produced.
II. Clinical Features of Somatization Disorder
A. Somatization disorder is a chronic problem, and
patients frequently seek medical treatment or
pursue multiple concurrent treatments. Patients
undergo multiple procedures, surgeries, and
hospitalizations. The disorder often begins during
adolescence.
B. Frequently encountered symptoms include nausea,
vomiting, extremity pain, shortness of breath, and
pregnancy or menstruation associated complaints.
C. The frequency and severity of symptoms may vary
with level of stress.
D. Two-thirds of patients have coexisting psychiatric
diagnoses. Mood and anxiety disorders and
substance-related disorders are common in
somatization disorder.
III. Epidemiology of Somatization Disorder
A. The lifetime prevalence is 0.1 to 0.5%. The
disorder is 5-20 times more prevalent in women.
The frequency of Somatization Disorder is
inversely related to social class.
B. Fifteen percent of patients have a positive family
history, and the concordance rate is higher in
monozygotic twins.
IV.Differential Diagnosis of Somatization Disorder
A. Medical conditions that present varied symptoms,
such as systemic lupus erythematosus, HIV or
multiple sclerosis, must be excluded.
B. Prominent somatic complaints can also be
associated with depression, anxiety, and
schizophrenia.
C. Malingering is suspected when there are external
motives (eg, financial) that would be furthered by
the intentional production of symptoms.
D. Factitious Disorder. In factitious disorder
symptoms are intentionally produced to assume
the sick role to meet a psychological need.
V. Treatment of Somatization Disorder
A. The physical complaints that occur in somatization
disorder are an expression of emotional issues.
Psychotherapy is beneficial to help the patient find
more appropriate and direct ways of expressing
their emotional needs. Behaviorally oriented group
therapy is also helpful.
B. The patient should have a primary care physician
and should be seen at regular intervals to minimize
inappropriate use of medical services.

Conversion Disorder
I. DSM-IV Criteria for Conversion Disorder
A. The patient complains of symptoms or deficits
affecting voluntary muscles, or deficits of sensory
function that suggest a neurological or medical
condition.
B. The temporal relation of symptoms to a stressful
event suggests association of psychological
factors.
C. Symptoms are not intentionally produced.
D. Symptoms are not explained by an organic
etiology.
E. Symptoms result in significant functional
 impairment.
F. Symptoms are not limited to pain or sexual
dysfunction, and are not explained by another
mental disorder.
II. Clinical Features of Conversion Disorder
A. The most common symptoms are sensory
(blindness, numbness) and motor deficits
(paralysis, mutism), and pseudoseizures. Other
symptoms include pseudocyesis (pregnancy),
urinary retention, torticollis and voluntary motor
paralysis (astasia-abasia).
B. Abnormalities usually do not have a normal
anatomical distribution and the neurological exam
is normal. Deficits tend to change over time.
C. Patients often lack the characteristic normal
concern about the deficit. This characteristic lack of
concern has been termed “la belle indifference.”
Conversion disorder can coexist with depression,
anxiety disorders, and schizophrenia.
D. Conversion symptoms often will temporarily remit
after the disorder has been suggested by the
physician.
III. Epidemiology of Conversion Disorder
A. Conversion disorder occurs in 1-30/10,000 in the
general population and in up to 3% of outpatient
psychiatric patients.
B. The disorder is more common in lower
socioeconomic groups.
IV.Differential Diagnosis of Conversion Disorder
A. Medical conditions must be excluded.
B. Somatization Disorder begins in early life and
involves multi-organ symptoms. Patients tend to be
very concerned about symptoms.
C. Factitious Disorder. Symptoms are under
conscious voluntary control, and they are
intentionally created to assume a sick role. In
conversion disorder, symptoms are not consciously
produced.
D. Malingering is characterized by the presence of
external motivations behind fabrication of
symptoms.
V. Treatment of Conversion Disorder
A. Symptoms typically last for days to weeks and
typically remit spontaneously. Supportive, insight-
oriented or behavioral therapy can facilitate
recovery.
B. Anxiolytics and relaxation may also be helpful in
some cases. The physician should avoid
confrontation or focusing on the symptoms. The
focus should be on psychological issues and any
secondary gain. Benzodiazepines can be useful
when anxiety symptoms are prominent.

Hypochondriasis
I. DSM-IV Criteria for Hypochondriasis
A. Preoccupation with fear of having a serious
disease, based on misinterpretation of symptoms.
B. The patient is not reassured by a negative medical
evaluation.
C. Symptoms are not related to delusions or restricted
to specific concern about appearance.
D. The disorder results in significant functional
impairment.
E. Duration is greater than six months.
F. Symptoms are not accounted for by another mental
disorder.
II. Clinical Features of Hypochondriasis
A. Despite clinical, diagnostic or laboratory evaluation,
the patient is not reassured. Doctor shopping is
common, and complaints are often vague and
ambiguous.
B. Repeated diagnostic procedures may result in
unrelated medical complications.
III. Epidemiology and Classification of
Hypochondriasis
A. The prevalence ranges from 4-9%.
Hypochondriasis is most frequent between age 20
to 30 years, and there is no sex predominance.
B. Hypochondriasis “with poor insight” is present if the
patient fails to recognize that his concern about
health is excessive or unreasonable.
IV.Differential Diagnosis of Hypochondriasis
A. Major depression, obsessive-compulsive disorder,
generalized anxiety disorder, and panic disorder
can often cause prominent somatic complaints with
no organic basis.
B. Medical conditions that can produce varied
symptoms, such as AIDS, multiple sclerosis, and
systemic lupus erythematosus, must be excluded.
C. Body Dysmorphic Disorder. Concerns are limited
only to physical appearance, in contrast to the fear
of having an illness that occurs in hypochondriasis.
 D. Factitious Disorder and Malingering.
Hypochondriacal patients realistically experience
the symptoms and do not fabricate them.
E. Conversion Disorder. This disorder tends to
cause only one symptom, and the patient has less
concern about the symptom.
F. Somatization Disorder. The focus of the patient is
on the symptoms, as opposed to fear of having a
disease in hypochondriasis.
V. Treatment of Hypochondriasis
A. Improvement usually results from reassurance
through regular physician visits. Cognitive-
behavioral group therapy, rather than individual
therapy, is most helpful.
B. Coexisting psychiatric conditions should be treated.
Hypochondriasis is sometimes episodic, and it may
be related to stressful life events. There is
preliminary evidence that SSRI medications are
beneficial.

Body Dysmorphic Disorder

I. DSM-IV Criteria for Body Dysmorphic Disorder
A. A preoccupation with imagined defect in
appearance.
B. The preoccupation causes significant functional
impairment.
C. Preoccupation is not caused for by another mental
disorder.
II. Clinical Features of Body Dysmorphic Disorder
A. Facial features, hair, and body build are the most
frequently “defective” features. Concerns about the
imagined defect may reach delusional proportions
without meeting criteria for a psychotic disorder.
Multiple visits to surgeons and dermatologists are
common.
B. Major depressive disorder and anxiety disorders
frequently coexist with body dysmorphic disorder.
III. Epidemiology of Body Dysmorphic Disorder
A. The disorder is most common between the ages of
15 and 20 years, with women affected as frequently
as men.
B. Family history reflects a higher incidence of mood
disorders and obsessive-compulsive disorder
(OCD).
IV.Differential Diagnosis of Body Dysmorphic
Disorder
A. Neurological “neglect” is seen in parietal lobe
lesions, and it can be mistaken for dysmorphic
disorder.
B. Anorexia Nervosa. Preoccupation about body
image are limited to concerns about being “fat.”
C. Gender Identity Disorder. Characterized by
discomfort with the patient’s own sex and
persistent identification with the opposite sex.
D. Narcissistic Personality Disorder. In this
disorder, concern with a body part is only one
feature in broad constellation of other personality
features.
V. Treatment of Body Dysmorphic Disorder. SSRI
antidepressants and clomipramine are effective in
reducing symptoms in 50% of patients, possibly due
to the similarities of this disorder to OCD. Cognitive
behavioral therapy may have some efficacy.
Coexisting psychiatric conditions, such as a mood
disorder, should be treated. Surgical repair of the
“defect” is rarely successful.

Factitious Disorder
I. DSM-IV Criteria
A. Intentional production of physical or psychological
symptoms.
B. The patients motivation is to assume the sick role.
C. External motives (financial gain) are absent.
II. Clinical Features of Factitious Disorder
A. Identity disturbance and dependent and
narcissistic traits are frequent. Patients with
physical symptoms often have histories of many
surgeries and hospitalizations.
B. Patients are able to provide a detailed history and
describe symptoms of a particular disease and
may intentionally produce symptoms (eg, use of
drugs such as insulin, self-inoculation to produce
abscesses). Common coexisting psychological
symptoms include depression or factitious
psychosis.
C. Great effort should be made to confirm the facts
presented by the patient and confirm the past
medical history. An outside informant should be
sought to provide corroborating information.
III. Epidemiology of Factitious Disorder
A. Begins in early adulthood.
B. More frequent in men and among health-care
workers.
IV. Classification of Factitious Disorder
A. With predominantly psychological signs and
symptoms.
B. With predominantly physical signs and symptoms
(also known as Münchhausen Syndrome).
C. With combined psychological and physical
symptoms.
D. Factitious disorder by proxy is characterized by the
production of feigning of physical signs or
symptoms in another person who is under the
person’s care (typically a child). This is considered
to be a form of child abuse.
V. Differential Diagnosis
A. Somatoform Disorders: Somatoform disorder
patients are less willing to undergo medical
procedures, such as surgery. Symptoms are not
fabricated.
B. Malingering: A recognizable goal for producing
symptoms is present.
C. Ganser’s syndrome refers to a condition
associated with prison inmates who give ridiculous
answers to questions (1 + 1 = 5) in an effort to
avoid responsibility for their actions.
VI. Treatment of Factitious Disorder
A. No specific treatment exists, and the prognosis is
generally poor.
B. The condition should be recognized early, and
needless medical procedures should be
prevented. Close collaboration between the
medical staff and psychiatrist is recommended.

References
References, see page 120.

Sleep Disorders
Primary Insomnia
Primary insomnia is characterized by the inability to
initiate or maintain sleep.

I. DSM-IV Criteria
A. Difficulty initiating or maintaining sleep when there
is no known physical or mental condition (including
drug related), resulting in significant distress or
impairment.
B. The disorder causes significant distress or
impairment in social or occupational functioning.
C. The disorder is not due to the effects of
medication, drugs of abuse, or a medical
condition.
II. Clinical Features
A. Anxiety or depression commonly coexist with
insomnia.
B. Mood disorders account for less than 50% of
insomnia.
C. Schizophrenia is associated with fragmented
sleep.
III. Differential Diagnosis
A. Dyssomnias, substance abuse, mood, anxiety, or
psychotic disorders may present with insomnia.
B. Many medical conditions can cause insomnia
including asthma, gastritis, peptic ulcer disease,
headaches.
C. Many drugs can disrupt sleep including beta-
blockers, calcium channel blockers, steroids,
decongestants, nicotine, stimulating
antidepressants, thyroid hormones, and
bronchodilators.
IV. Treatment
A. Temporary use (less than one month) of short-
acting benzodiazepines is especially helpful when
there is an identifiable precipitant (eg, death of a
loved one).
B. Zolpidem (Ambien) and zaleplon (Sonata) have
the advantage of achieving hypnotic effects with
less tolerance and less daytime sedation.
C. The safety profile of benzodiazepines and
benzodiazepine receptor agonists is good; lethal
overdose is rare, except when benzodiazepines
are taken with alcohol.
D. Zolpidem (Ambien) is a benzodiazepine receptor
agonist with a short elimination half-life that is
effective in inducing sleep onset and promoting
sleep maintenance. Zolpidem is associated with
greater residual impairment in memory and
psychomotor performance than zaleplon.
E. Zaleplon (Sonata) is a benzodiazepine receptor
 agonist that is rapidly absorbed (Tmax = 1 hour) and
has a short elimination half-life of one hour.
Zaleplon does not impair memory or psychomotor
functioning on morning awakening. Zaleplon does
not cause residual impairment when the drug is
taken in the middle of the night. It can be used at
bedtime or after the patient has tried to fall asleep
naturally.
F. Eszopiclone (Lunesta) is a benzodiazepine
receptor agonist with a 6- hour elimination half-life
that is effective in inducing sleep onset and
promoting sleep maintenance. Eszopiclone is
associated with greater residual impairment in
memory and psychomotor performance than
zaleplon.
G. Ramelteon (Rozerem) binds to melatonin
receptors MT1, MT2) and is useful for insomnia
characterized by difficulty with sleep onset. It does
not have abuse liability nor does it cause cognitive
impairment or CNS depression.
H. Benzodiazepines with long half-lives, such as
flurazepam (Dalmane), may be effective in
promoting sleep onset and sustaining sleep.
These drugs tend to accumulate and have effects
that extend beyond the desired sleep period,
resulting in daytime sedation or functional
impairment. This can be particularly problematic in
the elderly who have reduced metabolic clearance
of these medications.
I. Sedating antidepressants are sometimes used
as an alternative to benzodiazepines or
benzodiazepine receptor agonists. Amitriptyline
(Elavil), 25-50 mg at bedtime, doxepin (Sinequan)
50 mg, mirtazapine (Remeron) 7.5-15 mg or
trazodone (Desyrel), 50-100 mg, are common
choices.
J. Sleep Hygiene
1. Encourage patient to keep a consistent pattern
of waking, and sleeping at the same time each
day.
2. Avoid large meals before bedtime.
3. Discontinue stimulant caffeine, alcohol, or
nicotine.
4. Avoid daytime naps.
5. Engage in regular exercise, but avoid exercise
before sleeping.
6. Allow for a period of relaxation before bedtime
(hot bath).

Agents Used for Insomnia

Agent Dosage Ave Half- Comments

life of
Metabolite
s

Zolpidem 5-10 mg 3 hours Non-

(Ambien, qhs benzodiazepine;
Ambien CR) 6.25-12.5 no daytime
mg hangover.
CR provides
longer-term
action. 6.25 mg
dose is
recommended
for elderly.

Zaleplon 5 -10 mg 1 hour Non-

(Sonata) benzodiazepine;
no daytime
hangover

Eszopiclone 1-3 mg 6 hours Non-

(Lunesta) benzodiazepine

Triazolam 0.125-0.25 2 hours Short acting;

(Halcion) mg qhs some patients
can experience
perceptual
disturbances

Temazepam 7.5-30 mg 11 hours Benzodiazepine

(Restoril) qhs

Flurazepam 15-30 mg 100 hours, Hangover is

(Dalmane) qhs active common. Can
metabo- accumulate in
lites long t elderly.
½ Benzodiazepine.

Ramelteon 8 mg qhs metabolite Non-

(Rozerem) has little benzodiazepine;
activity half-life of
ramelteon is 1-2
hours; no abuse
liability
 Agent Dosage Ave Half- Comments
life of
Metabolite
s

Antidepressa
nts 25-100mg Long Priapism - rare.
Trazodone
(Desyrel)
50-100 mg Long Anticholinergic
Doxepin side effects
(Sinequan)
25-50 mg Long Anticholinergic
Amitriptyline side effects
(Elavil)
7.5-15 mg Long More sedating at
Mirtazapine lower doses.
(Remeron)

Antihistamin
es 50 mg NA Limited efficacy
Diphenhydra for mild initial
mine insomnia.
(Benadryl)

Primary Hypersomnia
I. DSM-IV Criteria for Primary Hypersomnia
A. Excessive somnolence occurs for one month in the
absence of physical or medical condition and is
associated with daytime sleepiness.
B. The disorder causes significant distress or
impairment in social or occupational functioning.
C. The disorder is not due to the effects of medication,
drugs of abuse, or a medical condition.
II. Clinical Features
A. Depression often coexists.
B. Can be associated with autonomic dysfunction.
C. May be familial.
D. Sleep architecture is normal.
III. Differential Diagnosis
A. Substance abuse, mood, anxiety, or psychotic
disorders may present with hypersomnia.
B. Atypical depression and the depressed phase of
bipolar illness may present with hypersomnia as an
isolated symptom.
IV.Treatment. For daytime sleepiness stimulants such
as amphetamine or methylphenidate (Ritalin), given in
the morning, are useful. Modafinil (Provigil) is a non-
amphetamine stimulant approved for treatment of
excessive daytime sleepiness associated with
narcolepsy. Modafinil is effective at a dosage of 100-
200 mg given in the morning.

Narcolepsy
I. DSM-IV Criteria for Narcolepsy
A. Excessive daytime sleepiness.
B. Sleep attacks with abnormal manifestations of
rapid eye movement sleep during the day. Sleep
attacks may be associated with hallucinations,
sleep paralysis, sleep onset REM, or cataplexy.
C. The disorder causes significant distress or
impairment in social or occupational functioning.
D. The disorder is not due to the effects of medication,
drugs of abuse, or a medical condition.
II. Clinical Features
A. Social reticence occurs due to fear of having sleep
attack. Sudden onset of sleep (cataplexy) can be
triggered by strong emotions.
B. Narcolepsy is often associated with mood
disorders, substance abuse, and generalized
anxiety disorder.
C. May be familial (>90% have HLA-DR2).
III. Differential Diagnosis: Sleep deprivation, primary
hypersomnia, breathing-related disorders,
hypersomnia associated with mental disorder, such as
depression, substance abuse, or a medical condition.
IV.Treatment: Stimulants, such as methylphenidate
(Ritalin), 10 mg bid or tid, are sometimes combined
with tricyclic antidepressants (Protriptyline10-20 mg)
before bedtime. Modafinil (Provigil) is a non-
amphetamine stimulant approved for treatment of
excessive daytime sleepiness associated with
narcolepsy. Modafinil is effective at a dosage of 200
mg given in the morning.
A. Sodium Oxybate (Xyrem) is a CNS depressant
that treats excessive daytime sleepiness and
cataplexy associated with narcolepsy. It is also
known as GBH and has abuse potential. It comes
in a liquid formulation and is titrated to a dose of 6-
9 grams/night.
Breathing-Related Sleep Disorder
(Sleep Apnea)
I. DSM-IV Criteria for Breathing-Related Sleep
Disorder
A. Sleep disruption leading to daytime sleepiness due
to a sleep-related condition.
B. The disturbance is not due to another mental
disorder (eg, depression) or to the effect of drugs
of abuse, medication or general medical condition
such as arthritis.
C. The disorder causes significant distress or
impairment in social or occupational functioning.
II. Clinical Features
A. Sleep apnea is associated with snoring, restless
sleep, memory disturbance, poor concentration,
depression, and anxiety disorders.
B. Nocturnal polysomnography demonstrates apneic
episodes, frequent arousals, and decreased slow
wave and rapid eye movement sleep.
C. Apnea can be central due to brain stem
dysfunction or obstructive caused by airway
obstruction. Obstructive sleep apnea is the most
common type.
III. Differential Diagnosis: Other Dysomnias, medical
conditions and substance abuse or withdrawal may
cause sleep disturbances.
IV.Treatment
A. Nasal continuous positive airway pressure
(NCPAP) is the treatment of choice.
B. Weight loss, nasal surgery, and uvuloplasty are
also indicated if they are contributing to the apnea.
Surgical interventions are not consistently effective.

Circadian Rhythm Sleep Disorder

I. DSM-IV Criteria for Circadian Rhythm Sleep
Disorder
A. Misalignment between desired and actual sleep
periods, which can occur with jet lag or shift work,
or can be idiopathic.
B. The disorder causes significant distress or
impairment in social or occupational functioning.
C. The disorder is not due to the effects of medication,
drugs of abuse, or a medical condition.
II. Clinical Features
A. With jet lag and shift work, performance can be
impaired during wakefulness.
B. Mood disorders, such as depression and mania,
can be precipitated by sleep deprivation.
III. Treatment
A. The body naturally adapts to time shifts within one
week.
B. Zolpidem (Ambien) or zaleplon (Sonata) can be
used to correct sleep pattern.
C. Melatonin (5-10mg), given at 9:00pm, can also be
helpful. Higher doses tend not to be as effective,
producing a sustained plasma level rather than a
brief “pulse” that serves as a signal.

Dyssomnias Not Otherwise

Specified
I. Nocturnal Myoclonus (periodic leg movements)
A. Abrupt contractions of leg muscles.
B. Common in elderly (40%).
C. Results in frequent arousals and daytime
somnolence.
D. Standard treatments include L-dopa and
benzodiazepines.
II. Restless Legs Syndrome
A. Painful or uncomfortable sensations in calves when
sitting or lying down.
B. Common in middle age (5%).
C. Massage, benzodiazepines, propranolol, opioids or
carbamazepine can be helpful. Clonazepam has
been effective in doses of 0.5-2.0mg q hs.
Substance-Abuse
Disorders
General Criteria
DSM-IV Diagnostic for Criteria Substance-Related
Disorders
I. Substance Intoxication
A. Intoxication is defined as a reversible syndrome
that develops following ingestion of a substance.
B. Significant maladaptive, behavioral or
psychological changes occur, such as mood
lability, impaired judgement, and impaired social or
occupational functioning due to ingestion of the
substance.
II. Substance Abuse
A. Substance use has not met criteria for
dependence, but has lead to impairment or
distress as indicated by at least one of the
following during a 12-month period:
1.Failure to meet work, school, or home
obligations.
2.Substance use during hazardous activities.
3.Recurrent substance-related legal problems.
4.Continued use of the substance despite
continued social problems.
III. Substance Dependence
A. The diagnosis of substance dependence requires
substance use, accompanied by impairment, and
the presence of three of the following in a 12-
month period:
1.Tolerance: An increased amount of substance
is required to achieve the same effect, or a
decreased effect results when the same amount
is used.
2.Withdrawal: A characteristic withdrawal
syndrome occurs, or the substance is used in an
effort to avoid withdrawal symptoms.
3.The substance is used in increasingly larger
amounts or over a longer period of time than
desired.
4.The patient attempts or desires to decrease use.
5.A significant amount of time is spent obtaining,
using, or recovering from the substance.
6.Substance use results in a decreased amount of
time spent in social, occupational, or
recreational activities.
7.The patient has knowledge that the substance
use is detrimental to his health, but that
knowledge does not deter continued use.
IV. Substance Withdrawal
A. A substance-specific syndrome develops after
cessation or reduction in the amount of substance
used.
B. The syndrome causes clinically significant distress
or impairment.
C. Symptoms are not due to a medical condition or
other mental disorder.
V. Substance-Induced Disorders
A. Substance-induced disorders include delirium,
dementia, persisting amnestic disorder, psychotic
disorder, mood disorder, anxiety disorder, sexual
dysfunction, and sleep disorder.
B. Diagnosis requires meeting criteria for specific
disorder with evidence that substance intoxication
and not another condition (medical disorder) has
caused the symptoms.
VI. Clinical Evaluation of Substance Abuse
A. The physician should determine the amount and
frequency of alcohol or other drug use in the past
month, week, and day. For alcohol use, the
number of days per week alcohol is consumed,
and the quantity consumed should be determined.
B. Effects of Substance Use on the Patient’s Life
1.Family Manifestations. Family dysfunction,
marital problems, divorce, physical abuse and
violence.
2.Social Manifestations. Alienation and loss of
friends, gravitation toward others with similar
lifestyle.
3.Work or School Manifestations. Decline in
work or school performance, frequent job
changes, frequent absences, requests for work
excuses.
4.Legal Manifestations. Arrests for disturbing the
peace or driving while intoxicated, stealing, drug
dealing, prostitution, motor vehicle accidents.
5.Financial Manifestations. Irresponsible
borrowing or owing money, selling of
possessions.
VII. Physical Examination
A. Intranasal cocaine use may cause damaged nasal
 mucosa. IV drug abuse may be associated with
injection-site scars and bacterial endocarditis.
B. Nystagmus is often seen in abusers of sedatives,
hypnotics, or cannabis. Mydriasis (dilated pupils) is
often seen in persons under the influence of
stimulants or hallucinogens, or in withdrawal from
opiates. Miosis (pinpoint pupils) is a classic sign of
opioid intoxication.
C. The patient should be assessed for the withdrawal
symptoms, such as an enlarged liver, spider
angioma, impaired liver function, ascites, and
signs of poor nutrition or presence of findings due
to chronic alcohol use.
VIII. Laboratory Evaluation of Substance Abuse
A. A UA, CBC, chemistry panel, liver function tests,
thyroid hormone, and serology should be
completed on all patients.
B. Impaired liver function and hematologic
abnormalities are common.
C. Illicit drugs may be detected in blood and urine.
D. When risk factors are present, HIV and Hepatitis C
testing should be done.
 Specific Substance-Induced Disorders

Intoxica- Withdraw- Dementia Psychotic Mood Anxiety Sexual Sleep

tion al delirium disorder disorder disorder dysfuncti disorder
delirium on

Alcohol I W P IW IW IW I IW

Ampheta- I I IW I I IW
mine

Caffeine I I

Cannabis I I I

Cocaine I I IW IW I IW

Hallucino- I I I I
gens

Inhalants I P I I I

Opioids I I I I IW

PCP I I I I

Sedative I W P IW IW W I IW
hypnotic
I = intoxication W = withdrawal P = persisting
Substance-Related Disorders
I. Alcohol, Sedatives, Hypnotics, and Anxiolytics
A. Diagnostic Criteria for Intoxication
1. Behavioral and psychological changes are
present.
2. One or more of the following: slurred speech,
incoordination, unsteady gait, nystagmus,
impaired attention or memory, stupor or coma.
B. Clinical Features of Intoxication
1. Amnesia is often present.
2. Behavioral disinhibition (aggressive or sexual
activity) is a common finding.
C. Addiction
1. Tolerance develops to sedative effects.
2. Tolerance to brainstem depressant effects
develops more slowly. As users require higher
doses to achieve a “high,” the risk for
respiratory depression is increased.
D. Withdrawal from Alcohol and other Sedatives
1. Detoxification may be necessary after
prolonged use of central nervous system
depressants, or when there are signs of abuse
or addiction.
2. Sedatives associated with withdrawal
syndromes include alcohol, benzodiazepines,
barbiturates, and chloral hydrate.
E. Detoxification of Patients Dependent on
Alcohol, Sedatives or Hypnotics
1. Provide a supervised stepwise dose reduction
of the drug or substitute a cross-tolerant,
longer-acting substance (diazepam), which has
less risk of severe withdrawal symptoms.
2. The cross-tolerated drug is given in gradually
tapering doses. To prevent withdrawal
symptoms, the dose of medication should be
reduced gradually over 1-2 weeks.
II. Cocaine
A. Diagnostic Criteria for Intoxication
1. Psychological or behavioral changes, such as
euphoria, hyperactivity, hypersexuality,
grandiosity, anxiety, or impaired judgement, are
present.
2. Two or more of the following: tachycardia or
bradycardia, mydriasis (dilated pupils), high or
low blood pressure, chills or perspiration,
nausea or vomiting, weight loss, agitation or
retardation, weakness, arrhythmias, confusion,
seizures, coma, respiratory depression,
dyskinesias, or dystonia.
B. Clinical Features of Cocaine Abuse
1. Irritability, poor concentration, insomnia, and
personality change are common. Intoxication
can result in euphoria, impulsive behavior, poor
judgement, and perceptual disturbances.
2. Physical sequelae include seizures, nasal
congestion and bleeding, cerebral infarcts, and
arrhythmias.
3. Chronic use is associated with paranoid
ideation, aggressive behavior, depression, and
weight loss.
C. Addiction. Psychological dependence is frequent.
Tolerance develops with repeated use.
D. Withdrawal is characterized by depression,
hypersomnia, anhedonia, anxiety, fatigue, and an
intense craving for the drug; withdrawal generally
remits in 2-5 days. Drug craving may last for
months.
E. Treatment
1. Hospitalization is sometimes required during
the withdrawal phase of treatment because of
the intense craving.
2. Clonidine, amantadine, carbamazepine and
tricyclic antidepressants (desipramine), may
decrease craving and are often adjuncts to
treatment.
III. Opioids
A. Diagnostic Criteria for Intoxication
1. Behavioral or psychological changes, such as
euphoria, followed by dysphoria, psychomotor
retardation, impaired judgement, or impaired
social or occupational functioning.
2. Pinpoint pupils (meiosis).
3. One of the following: drowsiness, coma, slurred
speech, or impairment in attention or memory.
B. Clinical Features of Opioid Abuse
1. Initial euphoria is followed by apathy, dysphoria,
and psychomotor retardation. Overdose can
result in coma, respiratory depression, and
death.
2. IV use is associated with risk of AIDS, skin
abscesses, and bacterial endocarditis.
C. Addiction. Tolerance and dependence develops
rapidly.
 D. Withdrawal
1. Intensity of the withdrawal syndrome is greatest
with opiates that have a short half-life, such as
heroin. Heroin withdrawal begins eight hours
after the last use, peaks in 2-3 days and can
last up to 10 days.
2. Diagnosis of withdrawal requires the presence
of three or more of the following: dysphoria,
nausea, vomiting, muscle aches, lacrimation,
rhinorrhea, mydriasis, piloerection, sweating,
diarrhea, yawning, fever, and insomnia.
E. Treatment of Heroin Addiction
1. For patients with respiratory compromise an
airway should be established and naloxone (0.4
mg IV) should be given immediately.
2. Withdrawal symptoms can be managed with
methadone (20-80 mg/day) buprenorphine or
clonidine (given orally or by patch). Clonidine
(0.1-0.3 mg qid) is effective and is usually used
as a first-line treatment of withdrawal. (Also see
Opiate Dependance, page 10.)
IV. Phencyclidine Abuse
A. Diagnostic Criteria for Intoxication
1. Behavioral changes.
2. At least two of the following: nystagmus,
hypertension or tachycardia, slurred speech,
ataxia, decreased pain sensitivity, muscle
rigidity, seizure or coma, hyperacusis.
B. Clinical Features of Phencyclidine Abuse
1. Behavior changes include violence,
belligerence, hyperactivity, catatonia,
psychosis, anxiety, impairment of attention or
memory, difficulty communicating.
2. Perceptual disturbances include paranoia,
hallucinations, and confusion.
3. Physical Examination: Fever, diaphoresis,
mydriasis.
4. Toxicology: PCP can be detected in urine for
up to 5 days after ingestion.
C. Addiction: No evidence of physical dependence
occurs, but tolerance to the effects can occur.
D. Withdrawal: Signs of depression can occur during
withdrawal.
E. Treatment of Phencyclidine Abuse
1. Benzodiazepines are the treatment of choice
(lorazepam 2-4 mg PO, IM or IV).
2. Psychosis is often refractory to treatment with
antipsychotics. Haloperidol (Haldol [2-4 mg
IM/PO]) every two hours can be used, but drugs
with anticholinergic side effects
(phenothiazines) should be avoided due to the
intrinsic anticholinergic effects of PCP.
3. Medical support is required if the patient is
unconscious.
V. Amphetamine/Methamphetamine (Speed, Crystal,
Crank)
A. Diagnostic Criteria for Amphetamine
Intoxication
1. Behavioral or psychological changes such as
euphoria, rapid speech, hyperactivity,
hypervigilance, agitation, or irritability.
B. Clinical Features
1. Euphoria and increased energy is common in
new users.
2. Development of delusions or hallucinations are
not unusual in chronic heavy users.
C. Addiction: Physical tolerance develops, requiring
increasing doses to achieve usual effect.
Psychological dependence is frequent.
D. Amphetamine Withdrawal
1. Generally resolves in one week and is
associated with increased appetite, vivid
dreaming, fatigue, anxiety, hypersomnia,
insomnia, psychomotor agitation or retardation.
2. Depression and suicidal ideation can develop.
E. Treatment
1. Antipsychotics can be used if psychosis is
present.
2. Benzodiazepines such as diazepam or
lorazepam may also help calm the patient.
VI. Nicotine
A. Intoxication does not occur.
B. Clinical Features
1. Craving is often prominent.
C. Addiction: Tolerance develops rapidly.
D. Diagnostic Criteria for Withdrawal
1. After abrupt cessation or reduction in the
amount of nicotine used, four or more of the
following occur within 24 hours: dysphoria,
insomnia, irritability, anxiety, poor
concentration, restlessness, decreased heart
rate, increased appetite.
E. Treatment
1. Nicorette gum or nicotine transdermal patches
 relieve withdrawal symptoms. Patients should
be prescribed a regimen that provides a
tapering dose over a period of weeks.

Treatments for Smoking Cessation

Drug Dosage Comments

Nicotine gum 2- or 4-mg Available OTC; poor

(Nicorette) piece/30 min compliance

Nicotine patch 1 patch/d for 6-12 Available OTC; local

(Habitrol, weeks, then taper skin reactions
Nicoderm CQ) for 4 week
*other OTC
b r a n d s
available

Nicotine nasal 1-2 doses/h for 6- Rapid nicotine

spray 8 weeks delivery; nasal
(Nicotrol NS) irritation initially

Nicotin e 6-16 cartridges/d Mimics smoking

i n h a l e r for 12 weeks behavior;
(Nicotrol provides low doses of
Inhaler) nicotine

Bupropion 150 mg/day for 3 Treatment initiated 2

(Zyban) d, then titrate to weeks before quit
300 mg day; contraindicated
with seizures,
a n o re x i a , h e a vy
alcohol use

F. Nicotine nasal spray (Nicotrol NS) is available by

prescription and is a good choice for heavy
smokers or patients who have failed treatment with
nicotine gum or patch. It delivers a high level of
nicotine, similar to smoking. The spray is used 6-8
weeks, at 1-2 doses per hour (one puff in each
nostril). Tapering over about six weeks.
G. Nicotine inhaler (Nicotrol Inhaler) delivers
nicotine orally via inhalation from a plastic tube. It
is available by prescription and has a success rate
of 28%, similar to nicotine gum.
H. Bupropion (Zyban)
1. Bupropion is appropriate for patients who have
been unsuccessful using nicotine replacement.
Bupropion reduces withdrawal symptoms and
can be used in conjunction with nicotine
replacement therapy. The treatment is
associated with reduced weight gain. Bupropion
is contraindicated with a history of seizures,
anorexia, heavy alcohol use, or head trauma.
2. Bupropion is started at a dose of 150 mg daily
for three days, then increased to 300 mg daily
for two weeks before the patient stops smoking.
Bupropion is then continued for three months.
When a nicotine patch is added to this regimen,
the abstinence rates increase to 50% compared
with 32% when only the patch is used.

References
References, see page 120.

Cognitive Disorders
Delirium
I. DSM-IV Diagnostic Criteria for Delirium
A. Disturbance of consciousness with reduced ability
to focus, sustain or shift attention.
B. The change in cognition or perceptual disturbance
is not due to dementia.
C. The disturbance develops over a short period of
time (hours to days) and fluctuates during the
course of the day.
D. There is clinical evidence that the disturbance is
caused by a general medical condition and/or
substance use or withdrawal.
II. Clinical Features of Delirium
A. Delirium is characterized by impairments of
consciousness, awareness of environment,
attention and concentration. Many patients are
disoriented and display disorganized thinking. A
fluctuating clinical presentation is the hallmark of
the disorder, and the patient may have moments
of lucidity during the course of the day.
B. Perceptual disturbances may take the form of
misinterpretations, illusions or frank hallucinations.
The hallucinations are most commonly visual, but
other sensory modalities can also be
misperceived.
C. Sleep-wake cycle disturbances are common, and
 psychomotor agitation can be severe, resulting in
pulling out of IVs and catheters, falling, and
combative behavior. The quietly delirious patient
may reduce fluid and food intake without overtly
displaying agitated behavior.
D. Failure to report use of medications or substance
abuse is a common cause of withdrawal delirium
in hospitalized patients. Infection and medication
interaction or toxicity is a common cause of
delirium in the elderly.
E. Injuries may occur when the patient is delirious
and agitated and unrecognized delirium may
result in permanent cognitive impairment.
F. The incidence of delirium in hospitalized patients
is 10-15%, with higher rates in the elderly. Other
patients at risk include those with CNS disorders,
substance abusers, and HIV-positive patients.
G. Post-discharge morbidity and mortality is higher in
patients who experience delirium compared to
those who do not.
III. Classification of Delirium
A. Delirium due to a general medical condition
(specify which condition).
B. Delirium due to substance intoxication (specify
which substance).
C. Delirium due to a substance withdrawal (specify
which substance).
D. Delirium due to a multiple etiologies (specify which
conditions).
E. Delirium not otherwise specified (unknown
etiology or due to other causes such as sensory
deprivation).
IV. Differential Diagnosis of Delirium
A. Dementia
1. Dementia is the most common disorder that
must be distinguished from delirium. The major
difference between dementia and delirium is
that demented patients are alert without the
disturbance of consciousness characteristic of
delirious patients.
2. Information from family or caretakers is helpful
in determining whether there was a pre-existing
dementia.
B. Psychotic Disorders and Mood Disorders with
Psychotic Features. Delirium can be
distinguished from psychotic symptoms by the
abrupt development of cognitive deficits including
disturbance of consciousness. In delirium, there
should be some evidence of an underlying
medical or substance-related condition.
C. Malingering. Patients with malingering lack
objective evidence of a medical or substance-
related condition.
V. Treatment of Delirium
A. Most cases of delirium are treated by correcting
the underlying condition.
B. Agitation, confusion, and perceptual disturbances
may require treatment with haloperidol (Haldol), 1-
2 mg given every 4-8 hours. Haloperidol is the
only antipsychotic available in IV form.
Intravenous administration may be necessary in
medically ill patients. Haloperidol may also be
given IM.
C. If patients are willing to take oral medication, small
doses of the sedating, low-potency medication
quetiapine (Seroquel) 12.5-25 mg every 4-8 hours
can be very effective. Monitoring of heart rate and
blood pressure is necessary in patients receiving
more than two doses per day. Parenteral forms of
ziprasidone (Geodon) and olanzapine (Zyprexa)
may have a role in managing delirium.
D. Agitation can also be treated with lorazepam
(Ativan), 1-2 mg every 2-6 hours PO, IM or IV.
Lorazepam is safe in the elderly and those
patients with compromised renal or hepatic
function. It should be used cautiously in patients
with respiratory dysfunction. It may cause
increased confusion.
E. A quiet environment with close observation should
be provided. Physical restraints may be necessary
to prevent injury to self or others.

Dementia
I. DSM-IV Diagnostic Criteria for Dementia
A. The development of multiple cognitive deficits
manifested by:
1. Memory impairment.
2. One or more of the following:
a. Aphasia (language disturbance).
b. Apraxia (impaired ability to carry out
purposeful movement, especially the use of
objects).
 c. Agnosia (failure to recognize or identify
objects).
d. Disturbance in executive functioning (abstract
thinking, planning and carrying out tasks).
B. The cognitive deficits cause significant social and
occupational impairment and represent a
significant decline from a previous level of
functioning.
C. The deficits are not the result of delirium.
II. Clinical Features of Dementia
A. The memory impairment involves difficulty in
learning new material and/or forgetting previously
learned material. Early signs may consist of losing
belongings or getting lost more easily.
B. Once the dementia is well established, patients
may have great difficulty performing activities of
daily living such as bathing, dressing, cooking, or
shopping.
C. Poor insight and impaired judgment are common
features of dementia.
1. Patients are often unaware of their deficits.
2. Patients may overestimate their ability to safely
carry out specific tasks.
3. Disinhibition can lead to poor social judgment,
such as making inappropriate comments.
D. Psychiatric symptoms are common and patients
frequently manifest symptoms of anxiety,
depression, and sleep disturbance.
E. Paranoid delusions (especially accusations that
others are stealing items) and hallucinations
(especially visual) are common.
F. Delirium is frequently superimposed upon
dementia because these patients are more
sensitive to the effects of medications and physical
illness.
III. Epidemiology of Dementia
A. The prevalence of dementia increases with age.
Three percent of patients over 65 years old have
dementia, but after age 85, 20% of the population
is affected.
B. Alzheimer’s type dementia is the most common
type of dementia, comprising 50-60% of all cases.
Vascular dementia is the second most common
cause of dementia, accounting for 13% of all
cases.
IV. Classification of Dementia
A. Alzheimer’s Type Dementia
1. The patient meets basic diagnostic criteria for
dementia but also:
a. Gradual onset and continued cognitive
decline.
b. Cognitive deficits are not due to another
medical condition or substance.
c. Symptoms are not caused by another
psychiatric disorder.
2. Alzheimer’s Disease is further classified as:
a. Early or late onset.
b. With delirium, delusions, depressed mood, or
uncomplicated.
3. The average life expectancy after onset of
illness is 8-10 years.
B. Vascular Dementia (previously Multi-Infarct
Dementia)
1. The patient meets basic diagnostic criteria for
dementia but also has:
a. Focal neurological signs and symptoms or
laboratory evidence of cerebrovascular
disease (eg, multiple infarctions on MRI
scan).
b. Vascular dementia is further classified as with
delirium, delusions, depressed mood, or
uncomplicated.
c. Unlike Alzheimer’s disease, changes in
functioning may be abrupt, and the long-term
course tends to have a stepwise pattern.
Deficits are highly variable depending on the
location of the vascular lesions, leaving some
cognitive functions intact.
C. Dementia Due to Other General Medical
Conditions
1. Meets basic diagnostic criteria for dementia, but
there must also be evidence that symptoms are
the direct physiological consequence of a
general medical condition.
2. AIDS-Related Dementia
a. Dementia caused by the effect of the HIV
virus on the brain.
b. Clinical presentation includes psychomotor
retardation, forgetfulness, apathy, impaired
problem solving, flat affect, social withdrawal.
c. Frank psychosis may be present.
d. Neurological symptoms are frequently
present.
3. Dementia Caused by Head Trauma. Dementia
 caused by head trauma usually does not
progress. The one notable exception is
dementia pugilistica, which is caused by
repeated trauma (eg, boxing).
4. Dementia Caused by Parkinson’s Disease.
Dementia occurs in 40-60% of patients with
Parkinson’s disease. The dementia is often
exaggerated by the presence of major
depression.
5. Dementia Caused by Huntington’s Disease
a. Dementia is an inevitable outcome of this
disease.
b. Initially, language and factual knowledge may
be relatively preserved, while memory,
reasoning, and executive function are more
seriously impaired.
c. Occasionally, dementia can precede the
onset of motor symptoms.
6. Dementia Caused by Pick’s Disease
a. The early phases of the disease are
characterized by disinhibition, apathy, and
language abnormalities because Pick’s
disease affects the frontal and temporal
lobes.
b. Later stages of the illness may by clinically
similar to Alzheimer’s disease. Brain imaging
studies usually reveal frontal and/or temporal
atrophy.
7. Dementia Caused by Creutzfeldt-Jakob
Disease
a. Creutzfeldt-Jacob disease is a subacute
spongiform encephalopathy caused by a
prion.
b. The clinical triad consists of dementia,
involuntary myoclonic movements, and
periodic EEG activity.
8. Lewy Body Dementia
a. Characterized by decline in cognition along
with fluctuating levels of attention and
alertness. Recurrent, well-formed visual
hallucinations are also common.
b. Lewy body dementia is associated with
repeated falls, transient loss of
consciousness, syncope, neuroleptic
sensitivity, delusions and hallucinations.
D. Substance-Induced Persisting Dementia
1. Meets basic diagnostic criteria for Dementia
but also:
a. The deficits persists beyond the usual duration
of substance intoxication or withdrawal.
b. There is evidence that the deficits are related
to the persisting effects of substance use
(specify which drug or medication).
2. When drugs of abuse are involved, most
patients have, at some time in their lives, met
criteria for substance dependence.
3. Clinical presentation is that of a typical
dementia. Occasionally patients will improve
mildly after the substance use has been
discontinued, but most display a progressive
downhill course.
E. Dementia Due to Multiple Etiologies. This
diagnosis is applicable when multiple disorders are
responsible for the dementia.

General Medical Conditions That Can Cause

Dementia

Vascular Neurological
Multiple infarcts Normal pressure
Subacute bacterial hydrocephalus
endocarditis Huntington’s disease
Congestive heart failure Parkinson’s disease
Collagen vascular diseases Pick’s disease
(eg, SLE) Brain tumor
Multiple sclerosis
Head trauma
Cerebral anoxia/hypoxia
Seizures

Nutritional Metabolic and Endocrine

Folate deficiency Hypothyroidism
Vitamin B12 deficiency Hyperparathyroidism
Thiamine deficiency Pituitary insufficiency
(Wernicke Korsakoff Diabetes
syndrome) Hepatic encephalopathy
Pellagra Uremia
Porphyria
Wilson’s disease

Infections Toxicity
HIV Heavy metals
Cryptococcal meningitis Intracranial radiation
Encephalitis Post-infectious
Sarcoid encephalomyelitis
Neurosyphilis Chronic alcoholism
Creutzfeldt-Jakob disease Industrial chemicals
V. Differential Diagnosis of Dementia
A. Delirium
1. Delirium is the most common disorder that may
mimic dementia. Differentiation of delirium from
dementia can be difficult because demented
individuals are prone to developing a
superimposed delirium.
2. Demented patients are alert, whereas, delirious
patients have an altered level of
consciousness. Delirious patients demonstrate
an acutely fluctuating clinical course, whereas
demented patients display a stable, slowly
progressive, downhill course.
B. Amnestic Disorder is characterized by isolated
memory disturbance, without the cognitive deficits
seen in dementia.
C. Major Depressive Disorder
1. Both dementia and depression may present
with apathy, poor concentration, and impaired
memory. Cognitive deficits due to a mood
disorder may appear to be dementia, and this
is referred to as “pseudodementia.”
2. Differentiation of dementia from depression can
be difficult, especially in the elderly. Demented
patients are often also depressed. In
depression, the mood symptoms should
precede the development of cognitive deficits
and in dementia, and the cognitive symptoms
should precede the depression.
3. A medical evaluation to rule out treatable
causes of dementia or medical causes of
depression should be completed.
4. If the distinction between dementia and
depression remains unclear, a trial of
antidepressants is warranted. If the depression
is superimposed on the dementia, treatment of
the depression will improve the functional level
of the patient.
VI. Clinical Evaluation of Dementia
A. All patients presenting with cognitive deficits
should be evaluated to determine the etiology of
the dementia. Some causes of dementia are
treatable and reversible.
B. A medical and psychiatric history and a physical
examination and psychiatric assessment, with
special attention to the neurological exam, should
be completed.
VII. Laboratory Evaluation of Dementia
A. Complete blood chemistry.
B. CBC with differential.
C. Thyroid function tests.
D. Urinalysis.
E. Drug screen.
F. Serum levels of all measurable medications.
G. Vitamin B12 level.
H. Heavy metal screen.
I. Serological studies (VDRL or MHA-TP).
J. EKG.
K. Chest X-ray.
L. EEG.
M. Brain Imaging (CT, MRI) is indicated if there is a
suspicion of CNS pathology, such as a mass
lesion or vascular event.
VIII. Treatment of Dementia
A. Any underlying medical conditions should be
corrected. The use of CNS depressants and
anticholinergic medications should be minimized.
Patients function best if highly stimulating
environments are avoided.
B. The family and/or caretakers should receive
psychological support. Support groups,
psychotherapy, and day-care centers are helpful.
C. Treatment of Alzheimer’s Disease
1. Donepezil (Aricept), Galantamine (Reminyl)
and Rivastigmine (Exelon) are the drugs of
choice for improving cognitive functioning in
Alzheimer’s dementia. They work by central,
reversible inhibition of acetylcholinesterase
thereby increasing CNS levels of acetylcholine.
It may slow progress of the disease.
a. Beginning dose is 5 mg qhs for donepezil,
which (after 4-6 weeks) may be increased to
10 mg qhs if necessary. Donepezil has no
reported hepatic toxicity or significant drug
interactions. Side effects include GI upset or
diarrhea.
b. Galantamine (Reminyl)is initiated at 4.0 mg
po bid for 4 weeks, then increased to 8.0 mg
po bid if tolerated for 4 weeks, and then up to
12 mg po bid.
c. Rivastigmine (Exelon) dosing is begun at
1.5 mg bid, increased to 4.5 mg bid and then
6.0 mg bid at two-week intervals. Efficacy is
greatest at the higher dose. The most
 common side effects are nausea, diarrhea
and syncope. GI side effects are reduced by
coadministration with food. There is no
hepatic toxicity.
2. Tacrine (Cognex) is a less-specific esterase
inhibitor that requires monitoring of AST and
SLT levels. Tacrine is not used due to its
hepatotoxicity.
3. Memantine (Namenda) is a noncompetitive
antagonist of the N-methyl-D-aspartate (NMDA)
receptor indicated for moderate-to-severe
dementia. Memantine may be used in
conjunction with an acetylcholinesterase
inhibitor. Dosing is 5 mg po q am, increased by
5 mg/week up to 10 mg po bid.
4. Vitamin E. Vitamin E and selegiline (Deprenyl)
may also have a role in slowing the progression
of dementia.
D. Treatment of Vascular Dementia
1. Hypertension must be controlled.
2. Aspirin may be indicated to reduce thrombus
formation.
E. Agitation and Aggression
1. Pharmacotherapy: The following agents have
significant efficacy in reducing agitation and
aggression in dementia.
a. Atypical Antipsychotics
i. Quetiapine (Seroquel) 12.5-25 mg po
qhs with an increase of 12.5 to 25 mg
every 1-3 days if needed to an average
dose of 25-200 mg/day and a maximum
dose of 400-600 mg/day.
ii. Risperidone (Risperdal), beginning at
0.25-0.5 mg qhs with an average dose of
0.5-2 mg day, is especially effective for
agitation associated with psychotic
symptoms such as paranoia.
iii. Olanzapine (Zyprexa), beginning at 2.5
mg qhs with an average dose of 2.5-7.5
mg qhs with an average dose of 2.5-7.5
mg qhs, also reduces agitation in
dementia.
iv. Ziprasidone (Geodon) 20 mg po bid with
increases of 20 mg every 1-3 days as
needed with maximum daily dose of 80
mg po bid.
v. Aripiprazole (Abilify) 2.5-5 mg po qhs up
to 10 mg if necessary.
vi. Haloperidol (Haldol) may be used if
atypical antipsychotics are ineffective or
poorly tolerated. Dose range is 0.5-5
mg/day given qhs or bid.
vii. Divalproex (Depakote) at a dosage of 10
mg/kg/day (250-1250 mg/day bid) is
effective and well tolerated by many
demented patients. Serum levels should
be maintained between 25-75 mg/mL.
viii. There have been reports of increased
risk of CVA in the elderly with
risperidone, olanzapine and
aripiprazole, prompting the FDA to
issue a general warning for the entire
class of atypicals.
ix. Buspirone (BuSpar) beginning at 5 mg
bid with a final dose of 30-50 mg/day in
bid or tid dosing. Buspirone has few side
effects and no significant drug
interactions. Several weeks are required
to achieve full benefit. Most commonly
used as an adjunct to antipsychotics.
x. Trazodone (Desyrel) beginning at 25-50
mg qhs with an average dose of 50-200
mg/day. Most commonly used as an
adjunct.
xi. Lorazepam (Ativan), 0.5-1.0 mg q 4
hours prn, can provide rapid relief, but it is
not recommended for long-term use
because of ataxia, further memory
impairment, and potential for disinhibition
and physical dependence.
F. Psychosis
1. High-potency typical antipsychotics, such as
haloperidol or fluphenazine, can be effective at
very low doses. Atypical antipsychotics are also
effective, often at much lower doses than used
in patients with primary psychosis.
2. Dosage increases should proceed with caution.
The elderly are prone to adverse effects due to
serum level accumulation including over-
sedation and hypotension.
G. Depression
1. SSRIs are first-line antidepressants in the
elderly. Venlafaxine (Effexor XR [75 mg to 225
mg]), bupropion (Wellbutrin), mirtazapine
(Remeron) and duloxetine (Cymbalta) may also
 be used if SSRIs are ineffective.
2. Tricyclic antidepressants should be avoided in
patients with dementia because of their
cardiovascular and anticholinergic effects.

References
References, see page 120.
Mental Disorders Due to a
Medical Condition
I. DSM-IV Diagnostic Criteria for Mental Disorder
Due to a Medical Condition
A. There is evidence from the history, physical exami-
nation, or laboratory studies that the symptoms are
a direct physiological consequence of a general
medical condition.
B. The disturbance is not better accounted for by
another mental disorder.
C. The disturbance is not caused by delirium.
II. Psychotic Disorder Caused by a General Medical
Condition
A. Diagnostic Criteria. The patient meets the criteria
for a mental disorder due to a general medical
condition and there are prominent hallucinations or
delusions.
B. Clinical Features of Psychotic Disorder Due to
a General Medical Condition
1. Hallucinations caused by a medical condition
include visual, olfactory and tactile elements
more often than in primary psychotic disorders.
2. Temporal Lobe Epilepsy is a common medical
condition associated with olfactory hallucina-
tions. Somatic and persecutory delusions are
the most common types of delusions associ-
ated with a medical condition.

Common Disorders Associated with Psychosis

Addison’s disease Lupus

CNS infections Multiple sclerosis
CNS neoplasms Myxedema
CNS trauma Pancreatitis
Cushing’s disease Pellagra
Delirium Pernicious anemia
Dementias Porphyria
Folic acid deficiency Temporal lobe epilepsy
Huntington’s chorea Thyrotoxicosis

C. Differential Diagnosis of Psychotic Disorder

Due to a General Medical Condition
1. Primary Psychotic Disorders
a. The onset of illness in a primary psychotic
disorder is usually earlier (before age 35), with
symptoms beginning prior to the onset of the
medical illness.
b. Complex auditory hallucinations are more
characteristic of primary psychotic disorders.
Non-auditory hallucinations (eg, tactile halluci-
nations) are more commonly seen in general
medical conditions.
2. Substance-Induced Psychotic Disorder
a. When psychosis is associated with recent or
prolonged substance use, withdrawal from a
substance is the likely cause. Blood or urine
screens for suspected substances may be
helpful in establishing this diagnosis.
b. Substances that can cause psychosis:
anticholinergics, steroids, amphetamines,
cocaine, hallucinogens, L-dopa, and
disulfiram.
D. Treatment of Psychotic Disorder Due to a Gen-
eral Medical Condition
1. The underlying medical conditions should be
corrected.
2. A trial of antipsychotic medication may be nec-
essary to manage symptoms while the patient’s
medical condition is being treated.
III. Mood Disorder Due to a General Medical Condi-
tion
A. Diagnostic Criteria. Meets criteria for a mental
disorder due to a general medical condition, and
the presence of a prominent and persistent mood
disturbance characterized by either or both of the
following:
1. With depressed mood or lack of pleasure in
most, if not all, activities.
2. Elevated, expansive, or irritable mood.
B. Clinical Features of Mood Disorder Due to a
General Medical Condition
1. The mood symptoms cannot be a merely psy-
chological reaction to being ill.
2. Subtypes include:
a. Mood disorder due to a general medical con-
dition with depressive features.
b. Mood disorder due to a general medical con-
dition with major depressive-like episode.
c. Mood disorder due to a general medical con-
dition with manic features.
d. Mood disorder due to a general medical con-
 dition with mixed features.

Common Diseases and Disorders Associated

with Depressive Syndromes

Addison’s disease Infectious hepatitis

AIDS Influenza
Anemia Lupus
Asthma Malignancies
Chronic infection (mononu- Malnutrition
cleosis, Multiple sclerosis
tuberculosis) Porphyria
Cushing’s disease Rheumatoid arthritis
Diabetes Syphilis
Heart failure Uremia
Hyperthyroidism Ulcerative colitis
Hypothyroidism

C. Differential Diagnosis of Mood Disorder Due to

a General Medical Condition
1. Primary Mood Disorder. If a clear causative
physiological explanation cannot be established
between mood symptoms and the medical con-
dition, a primary mood disorder should be diag-
nosed. Fluctuation of mood symptoms during
the course of medical illness is indicative of a
disorder due to a medical condition.
2. Substance-Induced Mood Disorder
a. When there is evidence of recent or pro-
longed substance use, a substance-induced
mood disorder is most likely. Blood or urine
screens may be helpful in establishing this
diagnosis.
b. Common substances that can cause de-
pressive syndromes include
antihypertensives, hormones (cortisone,
estrogen, progesterone), antiparkinsonian
drugs, benzodiazepines, alcohol, chronic
use of sympathomimetics, and withdrawal
from psychostimulants.
3. Treatment of Mood Disorder Due to a Gen-
eral Medical Condition. The underlying medi-
cal condition should be corrected.

References
References, see page 120.

Eating Disorders
Anorexia Nervosa
I. DSM-IV Diagnostic Criteria for Anorexia Nervosa
A. The patient refuses to maintain weight above 85%
of expected weight for age and height.
B. Intense fear of weight gain or of being fat, even
though underweight.
C. Disturbance in the perception of ones weight and
shape, or denial of seriousness of current low
weight.
D. Amenorrhea for three cycles in post-menarchal
females.
II. Classification of Anorexia Nervosa
A. Restricting Type or Excessive Dieting Type.
Binging or purging are not present.
B. Binge-Eating Type or Purging Type. Regular
binging and purging behavior occurs during
current episode (purging may be in the form of
vomiting, laxative abuse, enema abuse, or diuretic
abuse).
III. Clinical Features of Anorexia Nervosa
A. Anorexia nervosa is characterized by obsessive-
compulsive features (counting calories, hoarding
food), diminished sexual activity, rigid personality,
strong need to control ones environment, and
social phobia (fear of eating in public). Anorexia
nervosa commonly coexists with major depressive
disorder.
B. Two-thirds of patients with anorexia or bulimia
nervosa have a history of a major depressive epi-
sode.
C. Complications of Anorexia Nervosa. All body
systems may be affected, depending on the
degree of starvation and the type of purging.
Leukopenia and anemia, dehydration, metabolic
acidosis (due to laxatives), or alkalosis (due to
vomiting), diminished thyroid function, low sex
hormone levels, osteoporosis, bradycardia, and
encephalopathy are commonly seen.
D. Physical signs and symptoms may include
gastrointestinal complaints, cold intolerance,
emaciation, parotid gland enlargement, lanugo
hair, hypotension, peripheral edema, poor
dentition, and lethargy.
IV. Epidemiology of Anorexia Nervosa
A. Ninety percent of cases occur in females. The
prevalence in females is 0.5-1.0%. The disorder
begins in early adolescence and is rare after the
age of forty. Peak incidences occur at age 14 and
at age 18 years.
B. There is an increased risk in first-degree relatives,
and there is a higher concordance rate in
monozygotic twins. Patients with a history of
hospitalization secondary to anorexia have a 10%
mortality rate.
V. Differential Diagnosis of Anorexia Nervosa
A. Medical Conditions. Malignancies, AIDS,
superior mesenteric artery syndrome (postprandial
vomiting due to gastric outlet obstruction) are not
associated with a distorted body image nor the
desire to lose weight.
B. Body Dysmorphic Disorder. Additional
distortions of body image must be present to
diagnose this disorder.
C. Bulimia Nervosa. These patients are usually able
to maintain weight at or above the expected
minimum.
VI. Laboratory Evaluation of Anorexia Nervosa.
Decreased serum albumin, globulin, calcium,
hypokalemia, hyponatremia, anemia, and leukopenia
may be present. ECG may show prolonged QT
interval or arrhythmias.
VII.Treatment of Anorexia Nervosa
A. Pharmacotherapy of Anorexia Nervosa
1. There are a number of studies demonstrated
improvement in anorexia with SSRIs, with
fluoxetine (Prozac) having been most
commonly used at doses of 20-60 mg per day.
However, there are also a number of studies,
which showed negative results in anorexia with
SSRI treatment.
2. Trials of low-dose antipsychotic medications
have been described with varying success in
patients with anorexia. Medication-induced
weight gain can affect the acceptability of this
treatment and hasten non-compliance.
B. Psychotherapies include psychodynamic
psychotherapy, family therapy, behavioral therapy,
and group therapy.
C. Specialized treatment programs, including
behavioral treatment focusing on weight gain,
family psychotherapy, oral intake monitoring with
dietary consultation, and pharmacotherapy are
effective in motivated patients. Close monitoring of
body weight and the general medical condition is
warranted.
D. Hospitalization may become necessary if weight
loss becomes severe or if hypotension, syncope,
or cardiac problems develop.

Bulimia Nervosa
I. DSM-IV Diagnostic Criteria for Bulimia Nervosa
A. The patient engages in recurrent episodes of
binging, characterized by eating an excessive
amount of food within a two-hour span and by
having a sense of lack of self-control over eating
during the episode.
B. The patient engages in recurrent compensatory
behavior to prevent weight gain (eg, self-induced
vomiting, laxative, diuretic, exercise abuse).
C. The above occur on the average twice a week for
three months.
D. The patient’s self-evaluation is unduly influenced
by body shape and weight.
E. The disturbance does not occur exclusively during
episodes of anorexia nervosa.
II. Classification of Bulimia Nervosa
A. Purging Type Bulimia Nervosa. The patient
regularly makes use of self-induced vomiting, and
laxatives.
B. Nonpurging Type Bulimia Nervosa. The patient
regularly engages in fasting or exercise, but not
vomiting or laxatives.
III. Clinical Features of Bulimia Nervosa
A. Unlike anorexia patients, bulimic patients tend to
be at or above their expected weight for age.
Bulimic patients tend to be ashamed of their
behavior and often hide it from their families and
physicians.
B. There is an increased frequency of affective
disorders, substance abuse (30%), and borderline
personality disorder (30%) in bulimia patients.
C. Purging can be associated with poor dentition
(because of acidic damage to teeth). Electrolyte
abnormalities (metabolic alkalosis, hypokalemia),
dehydration, and various degrees of starvation can
 occur. Menstrual abnormalities are frequent.
Prognosis is generally better than for anorexia
nervosa, and death rarely occurs in bulimia.
IV. Epidemiology of Bulimia Nervosa
A. Bulimia occurs primarily in industrialized countries,
and the incidence is 1-3% in adolescent and young
adult females and 0.1-0.3% in males.
B. There is a higher incidence of affective disorders in
families of patients with bulimia, and obesity is
more common.
V. Differential Diagnosis of Bulimia Nervosa
A. Binging Purging Type Anorexia Nervosa. Body
weight is less than 85% of expected, and binging
and purging behavior occurs.
B. Atypical Depression. Overeating occurs in the
absence of compensatory purging behaviors, and
concern over body shape and weight is not
predominant.
C. Medical Conditions with Disturbed Eating
Behaviors. Loss of control, concern with body
shape, and weight are absent.
VI. Treatment of Bulimia Nervosa
A. The most effective therapy is cognitive behavioral
therapy. Psychodynamic group and family
therapies are also useful.
B. Pharmacotherapy of Bulimia Nervosa
1. Antidepressant medications are useful in the
treatment of bulimia nervosa, whether or not
accompanied by major depression; symptoms of
binging and purging are reduced.
2. SSRIs are most commonly used. Tricyclic
antidepressants should be used cautiously, if at
all, due to the risk of seizures and cardiotoxicity at
high doses or overdose.
3. Bupropion is contraindicated because of the
increased risk of seizures in bulimic patients.

References
References, see page 120.

Premenstrual Dysphoric Disorder

Premenstrual Dysphoric Disorder (PMDD) is
characterized by depressed mood prior to the onset of
menses.

I. DSM-IV Diagnostic Criteria

A. In most menstrual cycles over the past year, 5 or
more symptoms were present most of the time in
the last week of the luteal phase, began to remit
soon after the onset of the follicular phase, and
were absent in the week after menses, with at
least one of the symptoms being either (1), (2),
(3), or (4):
1. Markedly depressed mood, hopelessness, or
self-deprecating thoughts.
2. Marked anxiety, tension, feeling “keyed up” or
“on edge.”
3. Marked affective lability.
4. Persistent and marked anger or irritability or
increased interpersonal conflicts.
5. Decreased interest in activities.
6. Subjective sense of difficulty in concentrating.
7. Lethargy, easy fatigability, or marked lack of
energy.
8. Marked change in appetite, overeating, or
specific food cravings.
9. Hypersomnia or insomnia.
10.A subjective sense of being overwhelmed or
out of control.
11.Physical symptoms, such as breast tenderness
or swelling, headaches, joint or muscle pain, a
sense of “bloating,” weight gain.
B. The disturbance markedly interferes with work or
school or usual social activities and relationships
with others.
C. The disturbance is not merely an exacerbation of
the symptoms of another disorder, such as Major
Depression, Panic Disorder, Dysthymic Disorder,
or a Personality Disorder.
D. Criteria A, B and C must be confirmed by
prospective daily ratings during at least two
consecutive symptomatic cycles.
II. Clinical Features of Premenstrual Dysphoric
Disorder
A. Patients with PMDD do not experience symptoms
in the week following menses. Patients who have
continued symptoms after the onset of menses
may have another underlying psychiatric disorder.
B. The most severe symptoms of PMDD usually
occur in the few days prior to menses. It is
uncommon for women with dysmenorrhea to have
 PMDD and uncommon for women with PMDD to
have dysmenorrhea.
III. Epidemiology of Premenstrual Dysphoric
Disorder
A. The prevalence of PMDD ranges from 2-10% in
women. Onset usually occurs in the mid to late
twenties; however, onset in the teenage years
may sometimes occur.
B. Concomitant unipolar depression or bipolar
disorder or a family history of affective illness is
common in patients with PMDD.
IV. Differential Diagnosis of Premenstrual Dysphoric
Disorder
A. Premenstrual Syndrome. Many females
experience mild transient affective symptoms
around the time of their period. PMDD is
diagnosed only when symptoms lead to marked
impairment in social and occupational functioning.
B. Premenstrual Exacerbation of a Current Mood
or Anxiety Disorder. Females with disorders
such as dysthymia or generalized anxiety disorder
may experience a premenstrual exacerbation of
their depressive or anxiety symptoms. These
individuals will continue to meet criteria for a
mood or anxiety disorder throughout the
menstrual cycle; however, patients with PMDD
have symptoms only prior to and during menses.
V. Treatment of Premenstrual Dysphoric Disorder
A. Antidepressants. SSRIs, such as fluoxetine
(marketed as Sarafem for PMDD), are effective in
reducing symptoms of PMDD. The dosage of
fluoxetine (Sarafem) is 20 mg per day throughout
the month. The dosage may be increased up to
60 mg per day if necessary. Sertraline (Zoloft) is
also effective in treating PMDD. Sertraline should
be started at 50 mg per day and increased up to
150 mg if necessary. These agents are often
effective when given only during the luteal-phase.
Other SSRIs are equally effective.
B. Hormones. Estrogen, progesterone and triphasic
oral contraceptives may improve symptoms of
PMDD in some patients.
C. Spironolactone may improve physical symptoms,
such as bloating.
D. Anxiolytics. Alprazolam (Xanax) and buspirone
(BuSpar) may have efficacy in treating patients
with mild symptoms of anxiety.
E. Exercise. Moderate exercise can lead to
improvement of physical and emotional symptoms
of PMDD.

Psychiatric Drug Therapy

Antipsychotic Drug Therapy
I. Indications for Antipsychotic Drugs
A. Antipsychotics (also known as neuroleptics) are
indicated for schizophrenia, and these agents may
be used for other disorders with psychotic features,
such as depression and bipolar disorder.
B. Antipsychotics are the drugs of choice for brief
psychotic disorder, schizophreniform disorder and
schizophrenia. They also play a prominent role in
the treatment of schizoaffective and bipolar
disorder.
C. Antipsychotics may be necessary for patients with
mood disorders with psychotic features. Brief-to-
moderate courses are usually used. These agents
often improve functioning in patients with dementia
or delirium with psychotic features when given in
low doses.
D. Antipsychotics are frequently used in the treatment
of substance induced psychotic disorders. Low-
dose neuroleptics may be useful for the psychotic
features of severe personality disorders; however,
they should be used with caution and for a brief
period of time in these patients.
II. Selection of an Antipsychotic Agent. All
neuroleptics are equally effective in the treatment of
psychosis, with the exception of clozapine, which is
more effective for treatment refractory schizophrenia.
The newer “atypical” antipsychotics (risperidone,
olanzapine, quetiapine, ziprasidone, and aripiprazole)
may be more effective than conventional agents.
These newer agents are called atypical because they
affect dopamine receptors and also have prominent
effects on serotonergic receptors.
A. The choice of neuroleptic should be made based
on the past history of response to a particular
neuroleptic, family history of response, and
likelihood of tolerance to side effects.
 B. At least two weeks of treatment is required before
significant antipsychotic effect is achieved.
Symptoms will often continue to improve over the
following months. The use of more than one
antipsychotic agent at a time has not been shown
to increase efficacy.
III. Dosing of Antipsychotic Agents
A. Initial treatment for hospitalized patients with acute
psychosis usually begins with divided doses of the
antipsychotic, such as two to four times per day.
Olanzapine (Zyprexa), however, can be initiated
with once-a-day dosing. A multiple-dosing
schedule can address behavioral issues
throughout the day without exposing the patient to
the side effects associated with higher doses of
medication. This is particularly true of dose-related
side effects frequently seen with initiation of
medication, such as postural hypotension.
B. Outpatients are frequently given once-daily dosing,
usually at bedtime. This allows ease of
administration and increases compliance.
C. Once steady state levels have been achieved (after
about five days), the long half-life of most
neuroleptics permits once-a-day dosing.
Ziprasidone should be given in divided doses.
D. Agitated psychotic patients may require additional
sedative agents, such as benzodiazepines with
antipsychotic medication, until a clinical response
occurs.
IV.Route of Administration
A. Oral formulations are available for all
antipsychotics and some are available in liquid or
orally disintegrating form for elderly patients or to
increase compliance in patients who “cheek” their
medications and later spit them out.
B. Long-acting intramuscular (depot) neuroleptics,
such as risperidone (Consta), Haldol decanoate
and Prolixin decanoate are useful for non-
compliant patients.
1. Haldol decanoate should be started at twenty
times the daily oral dose in the first month of
treatment, divided into three or four IM injections
given over a seven-day period. For example, a
patient receiving 20 mg of oral haloperidol per
day would be given 400 mg of decanoate. The
dose may be reduced by 25% in each of the
next two months until the maintenance dose is
200 mg every 30 days.
2. Prolixin decanoate should be started at 25 mg
IM every two weeks with the dose adjusted up to
50 mg every two weeks if necessary.
3. Risperdal Consta should be started at 25 mg IM
every two weeks with the dose adjusted up to
50 mg every 4 weeks if necessary.
4. Once a patient has received one or two
injections, the oral antipsychotic can be
discontinued.
C. Short-acting IM formulations of ziprasidone and
olanzapine are available. The recommended dose
of IM ziprasidone is 10 mg every 2 hours or 20 mg
every 4 hours as required up to a maximum daily
dosage of 40 mg. Five to 10 mg of IM olanzapine
can be given every 2-4 hours up to a maximum
total dose of 30 mg. Haloperidol (Haldol) and
chlorpromazine (Thorazine) are often used in IM
form to treat acutely agitated psychotic patients.
Thorazine is usually given 25-50 mg IM with close
monitoring of blood pressure. Haldol 5-10 mg is
often given in conjunction with 1-2 mg of IM Ativan,
which provides sedation. Haldol is also available in
IV form. The use of IV Haldol is generally limited to
medical units when the patient is unable to take
oral medications and IV access is available.
V. Antipsychotic Side Effects
The following discussion is applicable primarily to the
typical antipsychotics. Atypical agents have a
relatively low incidence of extrapyramidal effects,
tardive dyskinesias, neuroleptic malignant syndrome,
and anticholinergic side effects.
A. Low-potency agents, such as chlorpromazine,
produce a higher incidence of anticholinergic side
effects, sedation and orthostatic hypotension
compared to high-potency agents such as
haloperidol.
B. High-potency agents, such as haloperidol and
fluphenazine, produce a high incidence of
extrapyramidal symptoms such as acute dystonic
reactions, Parkinsonian syndrome, and akathesia.
C. Moderate-potency agents include trifluoperazine
and thiothixene and have side effect profiles in
between the low- and high-potency agents.
D. Anticholinergic Side Effects
1. Neuroleptics, especially low-potency agents,
such as chlorpromazine and thioridazine,
produce anticholinergic side effects such as dry
 mouth, constipation, blurry vision, and urinary
retention.
2. In severe cases, anticholinergic blockade can
produce a central anticholinergic syndrome
characterized by confusion or delirium, dry
flushed skin, dilated pupils and elevated heart
rate.
Classification of Antipsychotic Drugs
Name Trade Class Average Chlorpro- Dopaminergic Muscari- Alpha-1 Antihist- Serotoner-
name Dose (mg) mazine Effect (D2) nic Effect Adrenergic amine gic Effect
Equivalents Blocking Effect
(mg) Effect
Chlorpromazine Thorazine Phenothia- 600-800 100 ++++ ++++ ++++ ++++ ++++
zine/Aliphatic
Fluphenazine Prolixin Phenothia- 10-20 2 ++++ + + ++ ++
zine/Piperazine
Perphenazine Trilafon Phenothia- 60-80 10 ++++ + ++ +++ ++++
zine/Piperazine
Trifluoperazine Stelazine Phenothia- 30-40 5 ++++ + ++ ++ +++
zine/Piperazine
Thioridazine Mellaril Phenothia- 600-800 100 ++++ ++++ ++++ ++++ ++++
zine/Piperidine
Mesoridazine Serentil Phenothia- 300-400 50 ++++ +++ ++++ ++++ ++++
zine/Piperidine
Haloperidol Haldol Butyrophenone 10-20 2 ++++ + + + ++
Clozapine Clozaril Dibenzodiazepine 300-600 60 ++ ++++ ++++ ++++ ++++
Aripiprazole Abilify Quinolone 15-30 2-4 ++++ + ++ ++ +++
Loxapine Loxitane Dibenzodiazepine 75-100 12.5 +++ ++ +++ ++++ ++++
Pimozide Orap Diphenylbut- 2-15 1 ++++ + + +
ylpiperidine
Molindone Moban Dihydroindolone 50-100 10 +++ ++ + + +
Thiothixene Navane Thioxanthene 30-40 5 ++++ + ++ +++ +
Risperidone Risperdal Benzisoxazole 2-8 1-2 ++ + +++ ++ +++
Olanzapine Zyprexa Thienoben- 5-20 3 +++ ++ ++ ++ +++
Zydis zodiazepine
Quetiapine Seroquel Dibenzothiazepine 400-600 50 + 0 ++ ++ ++
Ziprasidone Geodon Benzisothiazolyl 80-160 5-10 +++ + + + +++
piperzine
Paliperidone Invega Benzisoxazole 6-12 mg 2 ++ 0 ++ ++ +++
E. Extrapyramidal Side Effects (EPS)
1. Neuroleptics, especially the high-potency
agents, such as haloperidol, induce involuntary
movements known as extrapyramidal side
effects. These involuntary movements occur
due to blockade of dopamine receptors in the
nigrostriatal pathway of the basal ganglia.
2. Acute Dystonia
a. Acute dystonic reactions are sustained
contraction of the muscles of neck
(torticollis), eyes (oculogyric crisis), tongue,
jaw and other muscle groups, typically
occurring within 3-5 days after initiation of the
neuroleptic. Dystonias are often very painful
and frightening to patients.
b. Laryngeal spasms can cause airway
obstruction, requiring urgent intravenous
administration of diphenhydramine.
c. Dystonic reactions are most frequently
induced by high-potency neuroleptics such
as haloperidol and fluphenazine (Prolixin),
and can occur in young, otherwise healthy
persons (particularly younger men) even after
a single dose.
d. Dystonias (other than laryngospasm) should
be treated with 1-2 mg of benztropine
(Cogentin) IM. The patient may require long-
term anticholinergic medication to control the
dystonia. Dystonia may resolve over time
without changing the dose, but decreasing
the dose to the minimum effective dose
should be considered if dystonia develops.
Dystonias will often improve with a change to
a lower potency or atypical agent.
3. Drug-Induced Parkinsonian Syndrome
a. Patients with Parkinsonian syndrome
secondary to neuroleptics present with
cogwheel rigidity, mask-like facies,
bradykinesia, and shuffling gait. This is
similar to patients with idiopathic Parkinson’s
disease. Onset is usually after 2 weeks.
Older patient are at higher risk.
b. Drug-induced Parkinsonism is treated by
adding an anticholinergic agent such as
benztropine (Cogentin) or trihexyphenidyl
(Artane).
c. The dopamine releasing agent, amantadine,
is also effective.
d. Parkinsonian symptoms may also improve
with a lower dose of neuroleptic or after
switching to a low-potency agent such as
thioridazine or an atypical agent.
4. akathesia
a. Akathesia is characterized by strong feelings
of inner restlessness, which are manifest by
difficulty remaining still and excessive walking
or pacing.
b. Akathesia is very subjectively unpleasant and
is associated with medication noncompliance
and suicidality.
c. Akathesia frequently does not improve with
anticholinergic medication, but may respond
to a beta-blocker such as propranolol in the
dose range of 10-40 mg tid or qid.
Benzodiazepines such as diazepam are used
for refractory cases.
d. Lowering the medication dose or changing
antipsychotic may be required.
F. Tardive Dyskinesia (TD)
1. Tardive dyskinesia is an involuntary movement
disorder involving the tongue, mouth, fingers,
toes, and other body parts.
2. Tardive dyskinesias are characterized by
chewing movements, smacking and licking of
the lips, sucking movements, tongue
protrusion, blinking, grimaces and spastic
facial distortions.
3. All neuroleptics, with the exception of
clozapine, produce tardive dyskinesia. The risk
of tardive dyskinesia with atypical
antipsychotics is substantially decreased
compared to typical agents.
4. Antiparkinsonian drugs are of no benefit for
tardive dyskinesias and may exacerbate symp-
toms.
5. When tardive dyskinesia symptoms are
observed, the offending drug should be
discontinued immediately. Patients who
require continued neuroleptic therapy should
be switched to an atypical agent or clozapine
(if severe).
6. The risk of tardive dyskinesia increases with
the duration of neuroleptic exposure, and there
is an incidence of 3% per year with typical
agents.
 7. Most patients have relatively mild cases, but
tardive dyskinesia can be debilitating in severe
cases. Tardive dyskinesias do not always
improve or resolve with discontinuation or
lowering of the dose of neuroleptic.
G. Neuroleptic Malignant Syndrome (NMS)
1. NMS is a rare idiosyncratic reaction, which can
be fatal. All neuroleptics, with the exception of
clozapine, may produce NMS. The risk of NMS
with atypical antipsychotics is substantially
decreased.
2. NMS is characterized by severe muscle
rigidity, fever, altered mental status, and
autonomic instability. Laboratory tests often
reveal an elevated WBC, CPK, and liver
transaminases.
3. Treatment involves discontinuing the
neuroleptic immediately, along with supportive
treatment and medications such as
amantadine, bromocriptine, and dantrolene.
Patients may require treatment in an intensive
care unit.
H. Sedation. Neuroleptic sedation is related to
blockade of H-1 histamine receptors. It is more
common with low-potency agents, such as
chlorpromazine, compared to high-potency
agents, such as haloperidol. Bedtime
administration will often reduce daytime sedation.
I. Weight Gain. Olanzapine and clozapine are
associated with weight gain. Risperidone and
quetiapine have relatively less weight liability,
while aripiprazole and ziprasidone are considered
weight neutral. Blockade of the serotonin 2C and
histamine receptors may mediate this effect.
Weight gain, especially abdominal or “central
adiposity” is associated with increased risk for
development of Metabolic Syndrome character-
ized by increased fasting glucose, increased
triglycerides, low HDL, and hypertension.
J. Hyperlipidemia and Diabetes
1. Atypical antipsychotics are associated with
elevation of triglycerides and cholesterol and
the development of insulin resistance or type
II diabetes. Olanzapine and clozapine appear
to have the most risk followed by risperidone
and quetiapine. Aripiprazole and ziprasidone
have little or no risk.
2. Patients with serious mental illness are already
at risk for these disorders because of poor
diet, unhealthy lifestyle patterns and
decreased access to regular medical care;
therefore, it is important to aggressively
monitor patients for the presence or
development of lipid and glucose dysregulation
and encourage adoption of healthy lifestyles.
The following monitoring schedule of weight,
abdominal circumference, and metabolic
parameters should be followed (see table
below).

Monitoring Protocol for Patients on Atypical

agents (SDAs)*

Ba 4 8 12 Qu A Eve
se- wee wee wee ar- n- ry 5
lin ks ks ks t- n year
e er- u- s
ly all
y

Per- X X
son
al/-
fam-
ily
hist
ory

Wei X X X X X
ght
(BM
I)

Bloo X X
d
pres
sure

Fas- X X
ting
pla
sma
glu-
cos
e

Fas- X X X
ting
lipid
profi
le
 *More frequent assessments may be warranted based on clinical
status

K. Orthostatic Hypotension. Alpha-1 adrenergic

blockade results in orthostatic hypotension which
may be serious and can lead to falls and injury.
Orthostatic hypotension is especially common
with low-potency agents such as chlorpromazine,
thioridazine or clozapine. Patients should be
advised to get up slowly from recumbent
positions.
L. Cardiac Toxicity. Cardiac conduction delays can
occur with thioridazine, chlorpromazine or
pimozide in a dose-related fashion. Ziprasidone
may increase the QT interval, but this effect does
not appear to be clinically significant. The IM form
of ziprasidone does not have this effect on the QT
interval. Thioridazine has the greatest effect on
QT prolongation and should be used with caution.
Ziprasidone should be used with caution in
patients with known heart disease, a history of
syncope, a family history of sudden death, or a
history of congenital prolonged QT interval.
M. Sexual Side Effects
1. Antipsychotics may produce a wide range of
sexual dysfunction.
2. Dopamine receptor (D2) blockade can lead to
elevation of prolactin with subsequent
gynecomastia, galactorrhea, and menstrual
dysfunction.
3. Retrograde ejaculation, erectile dysfunction,
and inhibition of orgasm are also common side
effects.
N. Retinitis Pigmentosa. Irreversible blindness can
rarely occur with a dose of thioridazine greater
than 800 mg per day.
O. Photosensitivity. Antipsychotic agents often
cause photosensitivity and a predisposition to
sunburn. Photosensitivity is especially common
with low-potency agents, such as chlorpromazine.
Blue-purple or gray skin color can also result. This
is not always reversible. Patients should be
advised to use sunscreen.
P. Cholestatic jaundice is a rare hypersensitivity
reaction that is most common with
chlorpromazine. Cholestatic jaundice is usually
reversible after discontinuation of the medication.
Most cases develop during the third and fourth
weeks of treatment. Treatment should include
switching to another class of antipsychotic drug
after a drug-free interval.
VI. Atypical Neuroleptics
A. Clozapine (Clozaril) is a dibenzodiazepine
derivative and is considered an atypical
antipsychotic agent. Clozapine is used for the
treatment of patients who have not responded to,
or cannot tolerate, other neuroleptics.
1. Clozapine is associated with a 1% incidence of
agranulocytosis, which can be fatal. Weekly
monitoring of the WBC is recommended for
the first six months of treatment and every two
weeks thereafter. When white blood cell
counts drop below 3 x 1012/liter, clozapine
must be discontinued.
2. Eosinophilia (>4000/mm3) may be a precursor
of leukopenia. Clozapine should be
interrupted until count is below 3000/mm3.
3. Clozapine is unique in that it does not produce
extrapyramidal symptoms, tardive dyskinesia,
or NMS. The risk of seizures is increased at
dosages above 600 mg per day.
4. Clozapine causes sedation, orthostatic
hypotension, excess salivation (sialorrhea),
weight gain, tachycardia, and, rarely,
respiratory arrest in conjunction with
benzodiazepines. There is no significant
elevation of prolactin or subsequent side
effects.
B. Risperidone (Risperdal)
1. Risperidone has an atypical side-effect profile
with minimal extrapyramidal symptoms at
lower doses (up to 4-6 mg). At doses above 6
mg per day, the incidence of EPS increases
significantly. The effective dosage range is 2-8
mg/day.
2. Fatigue and sedation are the most common
side effects, followed by weight gain and
orthostatic hypotension.
3. Risperidone can elevate prolactin, leading to
gynecomastia, galactorrhea and disruption of
the menstrual cycle. Agranulocytosis has not
been reported. The incidence of tardive
dyskinesia is low.
C. Olanzapine (Zyprexa)
 1. Olanzapine has an atypical side-effect profile
with a low incidence of extrapyramidal
symptoms. The effective dose range is 5-20
mg/day, although some patients may require
higher doses. The typical starting dose is 10
mg/day.
2. Common side effects include sedation, weight
gain and dry mouth. Less frequent side effects
include orthostatic hypotension, nausea, and
tremor. There is no evidence of hemotoxicity.
Olanzapine levels may be decreased by
tobacco use or carbamazepine. Dose
reductions should be made in the elderly.
D. Quetiapine (Seroquel)
1. Quetiapine is an atypical neuroleptic with a
very low incidence of EPS. Initial dose is 25-50
mg bid, which is titrated every 1 or 2 days to a
total daily dose of 400-800 mg (given bid or
tid) for psychosis. A new XR formulation is
available that can be given once a day.
2. Side effects include sedation, orthostatic
hypotension and weight gain. Dyspepsia,
abdominal pain, and dry mouth may also
occur.
3. Initial and periodic eye exams (with slit lamp)
are recommended because of the occurrence
of cataracts in very high-dose animal studies.
Rarely described in humans. Dosage should
be reduced in the elderly. Sustained prolactin
elevation is not observed.
4. Due to its low-potency and broad therapeutic
index, quetiapine has found multiple off-label
uses at doses <100mg q day including
insomnia, non-specific anxiety,
E. Ziprasidone (Geodon)
1. Ziprasidone has an atypical side-effect profile
with a very low incidence of extrapyramidal
symptoms, weight gain, or effects on lipids and
glucose. The effective dose range is between
40-80 mg bid.
2. Ziprasidone can increase QT interval. While
there are no reports linking this to cardiac
arrhythmias, caution should be exercised in
patients with pre-existing increased QT interval
(from medications or cardiac disease). These
patients should have a baseline ECG.
3. Dizziness, nausea, and postural hypotension
are the most common side effects. Prolactin
elevation can occur.
4. Ziprasidone IM (Geodon IM) is available and
can be given 10 mg q 2-4 hours or 20 mg q 4
hours, not to exceed 40 mg/day. Somnolence
is more common with the IM form. QT
prolongation has not been observed with the
IM formulation.
F. Aripiprazole (Abilify)
1. Aripiprazole has an atypical side-effect profile
with a very low incidence of extrapyramidal
symptoms. This agent is a dopamine
autoreceptor agonist and post-synaptic D2
receptor partial agonist, giving it a unique
mechanism of action.
2. Aripiprazole has a low incidence of weight
gain, no effect on serum glucose or lipids and
no effect on QT interval. Effective dose is 10-
30 mg po per day.
3. Side effects occur infrequently but can include
akathesia, nausea and tremor.
G. Paliperidone (Invega)
1. Paliperidone is the active metabolite of
risperidone. Patients taking risperidone have
significant blood levels of paliperidone.
Paliperidone has a similar receptor affinity
profile.
2. Paliperidone comes in an extended-release
formulation that may improve tolerability as
compared to risperidone. It is prescribed in
doses from 6-12 mg, once daily.
VII. Anticholinergic and Antiparkinsonian Agents
A. Anticholinergic and antiparkinsonian agents are
used to control the extrapyramidal side effects of
antipsychotic agents, including acute dystonic
reactions, neuroleptic induced Parkinsonism, and
akathesia.
B. Indications
1. Anticholinergics are drugs of choice for acute
dystonias and for drug- induced Parkinsonism.
Intramuscular injections of anticholinergic
agents are most effective for rapid relief.
2. Anticholinergic agents are less effective for
drug-induced akathesia, which often requires
addition of a beta-blocker.
3. Antiparkinsonian agents are usually initiated
when a patient develops neuroleptic-related
extrapyramidal side effects, but they may be
 given prophylactically in high-risk patients. The
anticholinergic agent should be tapered and
discontinued after one to six months if
possible.

Classification of Anticholinergic and

Antiparkinsonian Agents

Name Trade Class Dose

Name

Benztro Cogentin Anticholi 1-2 mg bid-tid orally

pine nergic or 1-2 mg IM

Biperid Akineton Anticholi 2 mg bid-tid orally or

en nergic 2 mg IM

Trihex Artane Anticholi 2-5 mg bid-qid

yphen- nergic
idyl

Diphen Benadryl Antihist- 25-50 mg bid to qid

hydra- amine/ or 25-50 mg IM
mine Anti-
cholin-
ergic

Amanta Symmet- Dopamin 100-150 mg bid

dine rel e/
Agonist

4. Side Effects of Anticholinergic Agents

a. The most common side effects result from
peripheral anticholinergic blockade: dry
mouth, constipation, blurry vision, urinary
hesitancy, decreased sweating, increased
heart rate and ejaculatory dysfunction.
b. A central anticholinergic syndrome occurs
with high doses, or when the agent is
combined with other anticholinergic
medications. The syndrome is characterized
by confusion, dry flushed skin, tachycardia,
and pupillary dilation. In severe cases,
delirium, hallucinations, arrhythmias,
hypotension, seizures and coma may
develop.
c. Anticholinergic drugs are contraindicated in
narrow angle glaucoma and should be used
cautiously in prostatic hypertrophy or
cardiovascular disease.
d. Amantadine does not have anticholinergic
side effects; however, amantadine may
cause nausea, insomnia, decreased
concentration, dizziness, irritability, anxiety
and ataxia. Amantadine is contraindicated in
renal failure.

Antidepressants
I. Indications for Antidepressant Medication.
Unipolar and bipolar depression, organic mood
disorders, anxiety disorders (panic disorder,
generalized anxiety disorder, obsessive-compulsive
disorder, social phobia), schizoaffective disorder,
eating disorder, and impulse control disorders.
II. Classification of Antidepressants
A. Selective-Serotonin (5HT) Reuptake Inhibitors.
Fluoxetine (Prozac), sertraline (Zoloft), paroxetine
(Paxil), fluvoxamine (Luvox), citalopram (Celexa),
escitalopram (Lexapro).
B. Serotonin/Norepinephrine Reuptake Inhibitors.
Heterocyclics (TCAs), venlafaxine (Effexor),
duloxetine (Cymbalta).
C. Norepinephrine/Dopamine Reuptake Inhibitors.
Bupropion (Wellbutrin).
D. Mixed Serotonin Reuptake Inhibitor/Serotonin
Receptor Antagonists. Trazodone (Desyrel),
nefazodone.
E. Alpha-2-Adrenergic Antagonist. Mirtazapine
(Remeron).
F. Monoamine Oxidase Inhibitors (MAOIs).
Phenelzine, tranylcypromine, isocarboxazid.
G. Selective Norepinephrine Reuptake Inhibitor.
Atomoxetine (Strattera) - not FDA approved for
depression.
III. Clinical Use of Antidepressants
A. All antidepressants have been shown to have
equivalent efficacy. The selection of an agent
depends on past history of response, anticipated
tolerance to side effects, and coexisting medical
problems.
B. Once a therapeutic dose is reached, symptom
improvement typically requires 3-6 weeks. TCAs
 and bupropion have the narrowest therapeutic
index and present the greatest risk in overdose.
C. If no significant improvement is seen after an
adequate trial (4-6 weeks), then the dosage
should be increased or one may switch to a
medication in another antidepressant class.
Alternatively, an augmenting agent such as lithium
should be added.
D. When psychotic symptoms accompany severe
cases of depression, concomitant antipsychotic
medication is usually required and should be
discontinued when the psychosis abates.
E. Patients with three episodes of major depression
should be placed on long-term maintenance
treatment.
IV. Side Effects
A. Cardiac Toxicity
1. Tricyclic antidepressants may slow cardiac
conduction, resulting in intraventricular
conduction delay, prolongation of the QT
interval, and AV block. Patients with preexisting
conduction problems are predisposed to
arrhythmias; therefore, TCAs should not be
used in patients with conduction defects,
arrhythmias, or a history of a recent MI.
2. SSRIs, venlafaxine, bupropion, mirtazapine,
and nefazodone have no effects on cardiac
conduction.
B. Anticholinergic Adverse Drug Reactions. Dry
mouth, blurred vision, constipation, and urinary
retention.
C. Antihistaminergic Adverse Drug Reactions.
Sedation, weight gain.
D. Adverse Drug Reactions Caused by Alpha-1
Blockade. Orthostatic hypotension, sedation,
sexual dysfunction.
E. Serotonergic Activation. GI symptoms (nausea,
diarrhea), insomnia or somnolence, agitation,
tremor, anorexia, headache, and sexual
dysfunction can occur with SSRIs, especially early
in treatment.
F. Bupropion, mirtazapine and nefazodone are the
least likely to produce sexual side effects.
G. Discontinuation Syndrome. Sudden cessation
of SSRIs is associated with typical symptoms of
dizziness, fatigue, headache, nausea, insomnia,
shock-like sensations. While not dangerous, the
discontinuation syndrome is unpleasant and can
be avoided by taper of SSRIs. Intensity of the
syndrome is related to half-life with short half-life
SSRIs being associated with more rapid onset,
more intense but short-lived symptoms. Cross-
titration is not necessary when switching from one
SSRI to another with the exception of paroxetine.
Sudden cessation of paroxetine will provoke SSRI
discontinuation syndrome and a cholinergic
rebound syndrome (nausea, vomiting, diarrhea,
sialorrhea, diaphoresis) even if the patient begins
another SSRI immediately.
H. MAOIs. The most common adverse drug reaction
is hypotension. Patients are also at risk for
hypertensive crisis if foods high in tyramine
content or sympathomimetic drugs are consumed.
Despite the infrequent use of MAOIs, they remain
important for the treatment of refractory
depression.

Commonly Used Antidepressants

Drug Recommended Comments

dosage

Secondary Amine Tricyclics

Class as a whole: Side effects include anticholinergic effects (dry

mouth, blurred vision, constipation) and alpha-blocking effects
(sedation, orthostatic hypotension, cardiac rhythm disturbances).
May lower seizure threshold.

D e s i p r a m in e Initial dosage 25-50 May have CNS

(Norpramin, mg qhs, average stimulant effect.
generics) dose 150-250 mg/d,
May require dose of
300 mg/d. [10, 25,
50, 75, 100, 150 mg]

Protriptyline Initial dose of 5 mg q Less sedating than

(Vivactil) am increasing to 15- other TCAs.
40 mg/d in bid dosing
[5, 10 mg]
Drug Recommended Comments
dosage

Nortriptyline Initial dose 25 mg S e d a t in g. Serum

(Pamelor) qhs, increasing to 75- levels available.
150 mg/d; monitor
levels to achieve
serum level between
50-150 ng/mL. [10,
25, 50, 75 mg]

Tertiary Amine Tricyclics

Class as a whole: Anticholinergic effects and orthostatic

hypotension may be more severe than with secondary amine
tricyclics. All are contraindicated in glaucoma and should be used
with caution in urinary retention and cardiovascular disorders.

A m i t rip t yl i n e Initial dose of 25-50 High sedation. High

( E l a v i l , mg qhs increasing to anticholinergic activity.
generics) 150-250 mg/d. May
be given as single hs
dose. [10, 25, 50, 75,
100, 150 mg]

CIomipramine Initial dose of 25-50 Relatively high

(Anafranil) mg qhs increasing to sedation, anti-
150-250 mg/d; may cholinergic activity,
be given once qhs and seizure risk.
[25, 50, 75 mg]

D o x e p i n Initial dose of 25-50 High sedation, often

(Sinequan, mg/d, increasing to used as a hypnotic at
Adapin) 150-300 mg/d. [10, a dosage of 25-150
25, 50, 75, 100, 150 mg qhs.
mg]

Imipramine 75 mg/d in a single Relatively high

(Tofranil, dose qhs, increasing sedation. Also used to
generics) to 150 mg/d; max 300 treat enuresis.
mg/d. [10, 25, 50 mg]

Tetracyclic

Mirtazapine 15 mg qhs initially Sedation and appetite

(Remeron) increasing to 30-45 stimulation inversely
mg qhs over days to proportional to dose.
weeks [15, 30 mg] Minimal effect on
hepatic enzymes.

Maprotiline 75 mg qhs initially, Sedating. Substantial

(Ludiomil, Usual effective dose risk of seizures;
generics) 150 mg/d, max 225 maculopapular rash in
mg/d. [25, 50, 75 mg] 3-10%. Rarely used.

Amoxapine Initial dosage 25-50 May be associated

(Asendin) mg qhs, increase to with tardive
200-300 mg/d if d y s k i n e s i a ,
necessary. Max 600 neuroleptic malignant
mg/d. [25, 50, 100, s y n d r o m e ,
150 mg] galactorrhea.
Rarely used.

Selective-Serotonin Reuptake Inhibitors (SSRIs)

Class as a whole: Common side effects include sexual

dysfunction, headache, nausea, anxiety, mild sedation, insomnia,
anorexia.

Fluoxetine 10-20 mg/d initially, May be activating.

(Prozac) taken in AM; may Longest half-life of
require up to 80 any antidepressant (2-
mg/day for OCD and 9 days). Discontinue 2
bulimia [10, 20 mg months before
capsules / 20 mg/5 pregnancy. Significant
mL soln, 90 mg inhibition of CYP2D6
weekly tablet]

F l u vo xa m i n e 50 mg hs initially, Moderate sedation.

(Luvox) then increase up to Significant inhibition of
300 mg/day [25,50, CYP1A2
100 mg]

Paroxetine 20 mg hs initially; Moderate sedation

(Paxil, Paxil CR max of 80 mg/d. an d d ry m o u t h .
[extended rel- Elderly starting Significant inhibition of
ease]) dosage, 10 mg/d [10, CYP2D6.
20, 30, 40 mg; 10
mg/5mL oral solution;
12.5, 25, 37.5mg
continuous release
formulation]

Citalopram 20-60 mg/d [10, 20, Minimal sedation,

(Celexa) 40 mg tabs; activation, or inhibition
10mg/5mL oral of hepatic enzymes.
solution]

Escitalopram 10-20 mg qd [5, 10, Minimal sedation,

(Lexapro) 20 mg tabs; 5mg/5mL activation, or inhibition
oral solution] of hepatic enzymes.
 Drug Recommended Comments
dosage

Sertraline 50 qd, increasing as Minimal sedation,

(Zoloft) needed to max of 200 activation, or inhibition
mg/d [25,50, 100 mg of hepatic enzymes.
tabs; 20mg/mL oral
suspension]

Miscellaneous

Duloxetine 20 mg bid increasing Nausea, decreased

(Cymbalta) as needed to an appetite, dry mouth,
average of 30 mg bid dizziness, and sexual
and maximum of 60 dysfunction. Helpful
mg bid. [20, 30, and for syndromes
60 mg capsules] associated with
depression. Effective
for diabetic
neuropathy.

Nefazodone 50-100 mg bid Headache, dry mouth,

initially, increasing to blurred vision
150-300 mg bid. somnolence, postural
[50,100, 150, 200, hypotension, minimal
250 mg] sexual side effects or
inhibition of hepatic
enzymes. Rare
reports of liver failure.

Venlafaxine 37.5 mg bid initially Mild hypertension

(Effexor, increasing to 150-225 possible. Common
Effexor XR) mg/day in divided side effects: Nausea,
dose. Extended s o m n o lence ,
release (XR): 37.5-75 insomnia, dizziness,
mg/day increasing to sexual dysfunction,
150-225 mg/day [25, headache, dry mouth,
37.5, 50, 75, 100 mg] anxiety. Minimal or no
[XR: 37.5, 75, 100] inhibition of hepatic
enzymes.

Bupropion 100 mg bid initially Agitation, dry mouth,

(W ellbutrin, increasing to 100 mg insomnia, headache,
Wellbutrin SR, tid over 5 days. Slow nausea, vomiting,
Wellbutrin XL, release (SR): begin constipation, tremor.
Zyban) with 100-150 mg qd Good choice if sexual
for 3 days, increasing side effects from other
to 150 mg bid over 4- agents. Significant
7 days [75, 100 mg] inhibition of CYP2D6.
[SR: 100, 150, 200
mg] [XL: 150, 300 mg
tabs]

Trazodone 50-100 mg qhs Rare association with

(Desyrel) initially increasing priapism. Orthostatic
gradually to dose of hypotension. Highly
300-600 mg/day [50, sedating.
100, 150, 300 mg]

Mood Stabilizers
I. Indications for Mood Stabilizers
A. Mood stabilizers are the drugs of choice for bipolar
disorder, schizoaffective disorder, and cyclothymia.
They are effective for acute mania and for
prophylaxis of mania and depression in bipolar
disorders. Mood stabilizers are less effective for
bipolar depression.
B. These agents are sometimes effective for impulse
control disorders and aggressive behavior.
II. Valproic Acid (Depakote)
A. Valproic acid has become the mood stabilizer of
choice due to its favorable side-effect profile and
lower toxicity in overdose compared to lithium or
carbamazepine.
B. Valproic acid is effective for bipolar disorder,
schizoaffective disorder, and cyclothymia. It is also
used for impulse control disorders and aggression
in Cluster B personality disorders, dementia, or
mental retardation.
C. Valproic acid is more effective in rapid cycling and
mixed state episode bipolar disorder than lithium.
D. Treatment Guidelines
1. Valproate usually requires two weeks to take
full effect, but a trial of four to six weeks should
be completed before evaluating efficacy.
2. Serum levels, CBC, platelet count, and PT/PTT
should be obtained weekly during the first
month of treatment. Steady state levels can be
measured in 2-3 days.
3. Divalproex (Depakote) is the best tolerated
form of valproate. Divalproex is initiated at a
dosage of 20 μg/kg for rapid stabilization of
mania. This roughly corresponds to 500 mg tid
or 750 bid with titration up to a serum level of
50-125 mg/mL. The average dose is between
1500-3000 mg/day. Depakote ER (extended
release) tablets (500 mg) allow for once-a-day
 dosing. Depakote ER has 80-90%
bioavailability compared to Depakote.
4. Elderly patients require doses of approximately
half that of younger adults.
5. Valproate is more benign in overdose than
lithium or carbamazepine.
III. Lithium (Eskalith, Eskalith CR, Lithonate)
A. Lithium, in addition to being an antimanic agent,
possesses modest but significant antidepressant
properties. However, lithium is less effective than
valproate (Depakote) in rapid cycling mania.
B. Regular and slow-release forms of lithium
carbonate are available and either form may be
given twice daily initially switching to once-daily
dosing after several weeks.
C. Healthy young adults can usually tolerate 300-600
mg of lithium carbonate, twice daily at the start of
therapy. The dose is increased over seven to ten
days until the plasma level is 0.80-1.20 mEq/L
(0.80 to 1.20 mMol/L). Serum lithium levels are
measured 12 hours after the preceding dose of
lithium.
D. Common side effects of lithium include polyuria,
thirst, edema, weight gain, fine tremor, mild nausea
(especially if the drug is not taken with food), and
diarrhea.
E. Lithium toxicity is manifested by coarse tremor,
stupor, ataxia, seizures, persistent headache,
vomiting, slurred speech, confusion, incontinence,
and arrhythmias. Toxicity may occur when a
patient becomes ill and ceases to eat and drink
normally, but continues to take lithium. A patient
who cannot eat and drink normally should tem-
porarily discontinue lithium.
F. Serum lithium levels >2.0 (trough) can produce
permanent neurological impairment.
G. Nonsteroidal anti-inflammatory drugs, such as
ibuprofen or aspirin, and ACE inhibitors, elevate
the plasma lithium level. Lithium levels should be
carefully monitored. A reduction of lithium dose
may be required.
H. Lithium levels rise 20-25 percent when diuretics,
such as chlorothiazide (Diuril), are initiated. A
reduction of lithium dose may be required.
I. Laboratory evaluation prior to beginning treatment
with lithium should include blood urea nitrogen,
creatinine, electrolytes, fasting blood sugar, TSH,
free T4 levels, and an ECG in patients over 40
years or with pre-existing cardiac disease.
J. Side effects, such as tremor, may be reduced by
using divided doses or slow-release formulations.
The usual adult dosage ranges from 600-2400
mg/day. Two weeks are required for effect, and the
drug should be continued for four to eight weeks
before evaluating efficacy.
K. Serum levels must be drawn weekly for the first
one to two months, then every two to four weeks.
Serum levels should be kept between 0.8-1.2
mMol/L
L. Serum creatinine and TSH are monitored every 6
months.
M. Side Effects
1. Gastrointestinal distress (diarrhea, nausea)
may be reduced by giving the medication with
meals or by switching to a sustained release
preparation.
2. Tremor is most common in the hands. Tremor
is treated by lowering the dosage or by adding
low-dose propranolol (10-40 mg tid-qid).
3. Diabetes insipidus may result from lithium
administration. It presents with polyuria and
polydipsia. Treatment consists of amiloride
administration, in doses of 5-20 mg per day with
frequent monitoring of lithium and potassium
levels.
4. Hypothyroidism may result from lithium and is
treated with levothyroxine.
5. Dermatological side effects include acne,
which can be controlled with benzoyl peroxide
or topical antibiotics. Lithium can induce or
exacerbate psoriasis, which usually responds to
discontinuation of lithium.
6. Elevated WBC count, usually between 11-15
thousand, is frequently observed and requires
no treatment.
7. Cardiac side effects include T-wave flattening
or inversion and rare arrhythmias, which require
discontinuation of lithium.
8. Lithium toxicity may occur when levels exceed
1.5 mEq/liter. Toxicity presents with emesis,
diarrhea, confusion, ataxia, and cardiac arrhy-
thmias. Seizures, coma and death may occur at
levels above 2.5 mEq/liter. Treatment of
overdose may require hemodialysis.
IV. Carbamazepine (Tegretol)
A. Carbamazepine is used in patients who do not
respond to lithium. Carbamazepine is dosed bid or
tid to minimize side effects.
B. Treatment Guidelines
1. Pretreatment Evaluations. CBC with
differential and platelets, liver function tests,
EKG, electrolytes, creatinine and physical
examination.
2. Carbamazepine requires two weeks to take
effect, but a therapeutic trial should last at least
four to eight weeks.
3. Obtain serum levels (target is 8-12 μg/mL)
along with a CBC, liver function tests and
electrolytes weekly for a month. The WBC
should be monitored more frequently if the
white count begins to drop.
4. After the first month, levels may be drawn less
frequently.
5. Carbamazepine induces its own metabolism
and carbamazepine levels will decline between
three and eight weeks. At this time, the dosage
may need to be increased to maintain a
therapeutic blood level of 8-12 μg/mL.
C. Side Effects
1. The most serious side effects of
carbamazepine are agranulocytosis and
aplastic anemia, which occur at a frequency of
1 in 20,000.
2. Carbamazepine should be discontinued if the
total WBC count drops below 3,000 cells/mcL,
or if the absolute neutrophil count drops below
1,500 cells/mcL, or if the platelet count drops
below 100,000 cells/mcL.
3. Hepatitis may rarely occur, which may require
discontinuation of carbamazepine. Mild
elevations in liver function tests are seen in
most patients and this does not require
discontinuation of the drug.
4. Stevens-Johnson syndrome, a severe
dermatologic condition, is a rare side effect of
carbamazepine and requires immediate
discontinuation of therapy. Stevens-Johnson
syndrome begins with widespread purpuric
macules, leading to epidermolysis necrosis with
erosion of mucus membranes, epidermis and
severe constitutional symptoms.
5. Carbamazepine may also cause ataxia,
confusion, and tremors (usually with high doses
or toxicity). If this occurs the carbamazepine
dose should be decreased to achieve serum
levels of 8-12 μg/mL.
6. Carbamazepine decreases serum levels of
acetaminophen, antipsychotics,
benzodiazepines, oral contraceptives,
corticosteroids, cyclosporine, doxycycline,
phenytoin, methadone, theophylline, thyroid
supplements, valproate, warfarin, and
ethosuximide. Serum levels are decreased by
clomipramine and phenytoin.
7. Carbamazepine is more benign in overdose
than lithium.
D. Side Effects
1. Gastrointestinal distress (nausea and vomiting)
is the most common side effect, and these
symptoms often improve with coadministration
with food.
2. Sedation is common and usually abates in the
first few weeks. Hepatitis and pancreatitis are
rare complications and usually occur during the
first several months.
3. Mild elevations of liver function occur in many
patients and require no special treatment
except frequent monitoring of liver enzymes.
Thrombocytopenia is rare and may require
discontinuation of the drug if levels drop below
100,000.
4. Elevation of serum ammonia is a rare
complication and is often benign. Elevated
ammonia may, however, be an indicator of
severe hepatotoxicity, especially if
accompanied by confusion.
V. Gabapentin (Neurontin)
A. Controlled studies do not currently support the
efficacy of gabapentin in cyclical mood disorders.
B. Gabapentin has been used primarily as an
adjunctive treatment to other mood stabilizers
and/or antidepressants. It may be helpful for
anxiety, irritability and assist with sleep.
C. Treatment Guidelines
1. Renal function should be evaluated before
initiating treatment because gabapentin is
excreted unchanged renally. Impaired renal
function is not a contraindication to gabapentin;
 however, the dosage should be reduced in
patients with impaired renal function.
2. Starting dose is 300 mg q day with titration up
to an average daily dose of 900-1800 mg q day
in divided doses. Some studies have used up to
3600 mg/day. Given its short half-life, the time
between doses should not exceed 12 hours.
Serum levels are not useful because no
therapeutic window has been established.
3. Therapeutic effects can be seen in 2-4 weeks.
D. Side Effects
1. The most common side effects are
somnolence, fatigue, ataxia, nausea and
vomiting and dizziness. Gabapentin has been
reported to rarely cause anxiety, irritability,
agitation and depression.
2. Weight gain is an occasional side effect of
gabapentin.
VI. Lamotrigine (Lamictal)
A. Lamotrigine is an anticonvulsant. It is indicated for
the treatment of bipolar depression. It also appears
to be more effective in the treatment of depression
compared to other mood stabilizers, prompting
some clinicians to use it in the treatment of
resistant unipolar depression.
B. Lamotrigine has been successful as monotherapy
and as adjunctive treatment to other mood
stabilizers and/or antidepressants.
C. Treatment Guidelines
1. Pre-treatment evaluation should include an
assessment of renal and hepatic function
because both are involved in its excretion.
2. The initial dosage is 25 mg qd, increased
weekly to 50 mg/day, 100 mg/day, then 200
mg/day. Up to 400 mg may be required to treat
depression. Dosing can be either once or twice
a day.
3. Serum levels are not useful because the
therapeutic window has not been determined.
4. Coadministration with other anticonvulsants can
affect serum levels and should be used with
caution.
5. Therapeutic effect may be seen in 2-4 weeks.
D. Side Effects
1. The most common side effects are dizziness,
sedation, headache, diplopia, ataxia or
decreased coordination. The side effect most
likely to cause discontinuation of the drug is
rash (10%), which can be quite severe. Rash is
most common when lamotrigine is initiated at
higher doses or when titration is rapid.
2. The incidence of serious rash in adults is 0.3%
and can include Stevens-Johnson syndrome.
The risk for serious rash is higher in children
(0.8%).
3. Lamotrigine has been reported to cause
irritability, agitation, anxiety, mania and
depression.
4. Carbamazepine will lower lamotrigine levels
and valproate will increase lamotrigine levels.
VII. Topiramate (Topamax)
A. Topiramate is an anticonvulsant that has failed
clinical trials as a treatment for mania. Despite this
lack of efficacy data, it continues to be used as an
adjunctive treatment in bipolar disorder.
B. Treatment Guidelines
1. The starting dose is 25-50 mg/day, increasing
at increments of 25-50 mg per week to a target
dose of 200-400 mg/day, given in single dose
or bid. Therapeutic effects are seen in 2-4
weeks.
2. Topiramate is primarily excreted unchanged in
urine and has no effect on liver enzymes.
Plasma levels of topiramate can be reduced up
to 50% when combined with carbamazepine
and to a lesser degree with valproate.
Topiramate can reduce clearance of phenytoin
and impair the efficacy of oral contraceptives.
C. Side Effects
1. The most common side effects are sedation,
dizziness, ataxia, vision problems, speech
problems, memory impairment, and problems
with language processing.
2. Unlike other mood stabilizers, topiramate does
not cause weight gain and may promote weight
loss.
VIII. Tiagabine (Gabitril)
A. Tiagabine is a new anticonvulsant that is being
studied for efficacy as a mood stabilizer.
Uncontrolled studies suggest that it may be useful
as an adjunct to other mood stabilizers. Tiagabine
may have some efficacy for chronic pain and
anxiety.
B. Tiagabine is hepatically metabolized, but it does
not appear to induce hepatic enzymes. Tiagabine
 does not affect the metabolism of other
medications. Clearance may be decreased up to
60% when combined with carbamazepine,
phenytoin, or phenobarbital.
C. The initial dose is 4 mg/day, increasing by 4 mg at
weekly intervals to 12 mg/day, given in single dose
or bid. The typical maintenance dose for seizures
is 24-32 mg/day given bid or qid.
D. The most common side effects are dizziness, lack
of energy, somnolence, nausea, nervousness, and
tremor.
IX. Oxcarbazepine (Trileptal)
A. Oxcarbazepine is a new anticonvulsant that is
being studied for efficacy as a mood stabilizer.
Controlled studies suggest that it is effective in
mania at doses between 900-2400 mg/day.
B. The most common side effects are somnolence,
dizziness, diplopia, ataxia, nausea, vomiting and
rash.
X. Levetiracetam (Keppra) has been approved for
treatment of partial seizures. Its efficacy for affective
illness is unknown.

Mood Stabilizers
Name Trade Dosage Dose Therapeutic
Name Forms Range Drug Levels

Divalpro Depako 125, 250 500-4000 50-125

ex te or 500 mg in bid mcg/mL
sodium mg; 125 dosing
mg
sprinkle
capsules

Divalpro Depako 250 or 500-4000 50-125

ex te ER 500 mg mg in bid mcg/mL
sodium dosing
extende
d
release

Lithium Lithona 300 mg 600-2400 0.8-1.2

carbonat te, mg mEq/liter
e Eskalith

Lithium Lithobid 300 or 600-2400 0.8-1.2

carbonat , 450 mg mg mEq/liter
e, slow Eskalith
release CR

Lithium Cibalith 8 mEq/5 10-40 mL 0.8-1.2

citrate -S mL mEq/liter

Carbam Tegreto 100 or 400-1800 8-12 mcg/mL

azepine l, 200 mg mg in bid-
generic qid dosing
s
Liquid: 400-1800 8-12 mcg/mL
100 mg in bid-
mg/5 mL qid dosing

Valproic Depake 250 mg 500-3000 50-125

acid ne mg in bid mcg/mL
dosing

Gabape Neuron 100, 300-800 not

ntin tin 300, 400 mg tid applicable
mg

Lamotrig Lamicta 25, 100, 100-400 not

ine l 150, 200 mg applicable
mg

Tiagabin Gabitril 4, 12, 12-mg qd not

e 16, 20 or in applicable
mg divided
dose

Topiram Topam 25, 100, 200-400 not

ate ax 200 mg mg qd or applicable
in divided
dose

Antianxiety Agents
I. Benzodiazepines
A. Indications. Benzodiazepines are used for the
treatment of anxiety disorders, insomnia, seizure
disorders, and alcohol detoxification. They are also
effective adjunctive agents for agitated psychotic or
depressive states.
1. The primary indications for long-term treatment
are chronic anxiety disorders such as
generalized anxiety disorder and panic disorder.
All benzodiazepines induce tolerance and are
addictive. Short courses of treatment should be
used whenever possible. When
benzodiazepines are discontinued, the drug
should be tapered slowly. Long-acting agents,
such as clonazepam and diazepam, are
preferable for long-term treatment because they
 cause less withdrawal and require less frequent
dosing.
2. The 3-hydroxy-benzodiazepines (lorazepam,
alprazolam, oxazepam) have no active
metabolites and are the agents of choice in
patients with impaired liver function.
3. Acute agitation usually is treated with lorazepam
(Ativan), 2 mg IM because it is well tolerated
and effective in most patients.
B. Side Effects
1. Sedation is the most common and universal
side effect of benzodiazepines. Tolerance to
sedative effects often occurs during the first few
weeks of treatment.
2. Cognitive Dysfunction. Anterograde amnesia
is common after benzodiazepine use, especially
with high-potency agents (alprazolam) or short-
acting agents (triazolam).
3. Miscellaneous Side Effects
a. Benzodiazepines may produce ataxia,
slurred speech, and dizziness. Respiratory
depression can occur at high doses,
especially in combination with alcohol or
respiratory disorders, such as chronic
obstructive pulmonary disease.
b. Benzodiazepines are contraindicated in
pregnancy or lactation.

Antianxiety Agents

Name Trade Dose Dose Half-Life

Name (mg) Equiva of
lence Metabolit
es
(hours)

Alprazola Xanax 0.25-2 0.5 6-20

m tid/qid

Chlordiaz Libriu 25-50 10 30-100

epoxide m tid/qid

Clonazep Klonop 0.25-2 0.25 18-50

am in bid/tid

Clorazep Tranxe 7.5 -30 7.5 30-100

ate ne bid

Diazepa Valium 2-15 5 30-100

m bid/tid

Halazepa Paxipa 20-80 20 30-100

m m bid

Lorazepa Ativan 0.5–2 1 10-20

m tid/qid

Oxazepa Serax 15-30 15 8-12

m tid/qid

II. Buspirone (BuSpar)

A. Buspirone is a nonbenzodiazepine anxiolytic agent
of the azaperone class.
B. Indications
1. Buspirone (BuSpar) is indicated for anxiety
disorders, such as generalized anxiety disorder
but not panic disorder.
2. Buspirone may also be an effective adjunctive
agent in the treatment resistant depression.
Buspirone may be added in a dosage of 15-60
mg/day if a patient has had a suboptimal
response to a 3-6 week trial of an
antidepressant.
C. Dosage
1. The starting dose is 5 mg two to three times a
day. Gradually increase to a maximum dosage
of 60 mg per day over several weeks. Many
patients respond to a total dose of 30-40 mg per
day in two to three divided doses.
2. At least two weeks are required before clinical
improvement occurs.
D. Side Effects
1. Buspirone is generally well tolerated; the most
common side effects are nausea, headaches,
dizziness, and insomnia.
2. Buspirone is not addicting and has no
withdrawal syndrome or tolerance. It does not
produce sedation or potentiate the effects of
alcohol.

References
References, see page 120.

Somatic Therapies
Electroconvulsive Therapy
Electroconvulsive therapy (ECT) is a highly effective
treatment for depression, with a response rate of 90%,
compared to a 70% response rate for antidepressants.

I. Indications
A. Electroconvulsive therapy is effective for major
depressive disorder, bipolar affective disorder (to
treat mania and depression), catatonic stupor, and
acute psychosis.
B. Electroconvulsive therapy could be used as a first-
line treatment for depression, but this rarely occurs.
It is considered early in the treatment course if the
pt is catatonic, actively attempting to harm
themselves, unable to tolerate antidepressants for
medical reasons or is refusing to eat/drink as a
result of depression.
C. Special populations in which ECT is highly effective
include: elderly patients (especially those who
cannot tolerate therapeutic doses of
antidepressants), pregnant women (reported safe
in all 3 trimesters and even post-partum) and
treatment-resistant patients.
D. Depression in Parkinson’s disease responds to
ECT with the added benefit of improvement of the
movement disorder.
II. Electroconvulsive Therapy Evaluation
A. Pretreatment evaluation should include a complete
a history and physical, routine laboratory tests
(CBC, electrolytes, liver enzymes, urinalysis,
thyroid function), EKG, chest X-ray, spinal X-ray
series, and brain CT scan.
B. Informed consent should be obtained 24 hours
prior to the first treatment. A second psychiatrist,
not involved in the treatment of the patient, must
also examine the patient and document the
appropriateness of ECT and the patient’s ability to
give informed consent.
C. Electroconvulsive Therapy Procedure
1. The patient should be NPO for at least eight
hours and blood pressure, cardiac activity,
oxygen content, and the electroencephalogram
should be monitored.
2. A short-acting barbiturate, such as
methohexital, is administered for anesthesia. A
tourniquet (to prevent paralysis) is applied to
one extremity in order to monitor the motor
component of the seizure.
3. Muscle paralysis is then induced by
succinylcholine. After an airway has been
established, a rubber mouth block is then
placed and an electrical stimulus is applied to
induce the seizure.
4. The duration of the seizure is monitored by EEG
and by observing the isolated extremity.
D. Dose
1. The seizure must last a minimum of 25 seconds
and should not last longer than two minutes. If
the seizure lasts less than 25 seconds, wait one
minute and then stimulate again. Electrical
stimulation should be discontinued after three
failed attempts.
2. If seizures exceed two minutes, intravenous
diazepam is used to terminate the seizure.
3. Treatments are given two to three times per
week. A minimum of six treatments are usually
required (common course is 8-12 treatments).
The first three are often performed with bilateral
electrode placement. Up to twenty treatments
may be necessary before maximum response is
attained.
III. Contraindications to Electroconvulsive Therapy
include intracranial mass, recent stroke and recent
MI. The procedure is very safe, and the complication
rate is comparable to that of anesthesia alone.
IV. Side Effects of Electroconvulsive Therapy
A. Memory Loss. Retrograde and anterograde
amnesia of the events surrounding the treatment
is common. Loss of recent memory usually
resolves within a few days to a few weeks. A small
number of patients complain of persistent memory
difficulties after several months.
B. Headache is common after ECT, and it usually
resolves with analgesics in a few hours.
V. Maintenance Electroconvulsive Therapy
A. Infrequently, maintenance ECT may be required
for up to six months after the end of the initial
series of 8-12 treatments.
B. Treatments are given weekly for one month and
then gradually tapered to one treatment every four
to five weeks. Some patients may require long-
term treatment.
Transcranial Magnetic Stimulation
I. Mechanism
A. Repetitive transcranial magnetic stimulation
(rTMS) uses an electric coil to generate magnetic
fields that stimulate the cerebral cortex. It is very
well tolerated by patients and, in contrast to ECT,
does not require the use of anesthesia and does
not appear to cause cognitive impairment.
B. Randomized, controlled studies of rTMS have
produced conflicting results. A systematic review
concluded that there is no strong evidence of
benefit with rTMS in depressed patients. A
subsequent randomized trial of rTMS in 60
patients with treatment-resistant depression
showed a significantly higher rate of response in
two active treatment groups compared with
placebo; the absolute benefit, however, was
relatively small.
II. Adverse effects are limited to mild pain or
discomfort at the stimulation site and possible facial
twitching. TMS has not been approved by the FDA for
the treatment of depression.

Vagus Nerve Stimulation

Vagus nerve stimulation (VNS) was originally developed
and approved for the treatment of refractory seizure
disorders. VNS appears to be effective in the treatment
of moderate treatment-resistant depression. A
pacemaker-like pulse generator is implanted under the
skin in the upper left chest. A stimulation electrode
connected to the generator is tunneled from the chest to
the neck where it is attached to the left vagus nerve. The
most common adverse effect associated with VNS is
voice alteration or hoarseness.

References

American Psychiatric Association. Diagnostic and

Statistical Manual of Mental Disorders. 4th edition,
Washington, D.C., American Psychiatric Association,
1994.

Additional references may be obtained at

www.ccspublishing.com/ccs

Selected DSM-IV Codes

ATTENTION-DEFICIT AND DISRUPTIVE BEHAVIOR
DISORDERS
314.xx Attention-Deficit/Hyperactivity Disorder
.01 Combined Type
.00 Predominantly Inattentive Type
.01 Predominantly Hyperactive-Impulsive Type

DEMENTIA
290.xx Dementia of the Alzheimer’s Type, With Early
Onset (also code 331.0 Alzheimer’s disease on
Axis III)
.10 Uncomplicated
290.xx Dementia of the Alzheimer’s Type, With Late
Onset (also code 331.0 Alzheimer’s disease on
Axis III)
.0 Uncomplicated
290.xx Vascular Dementia
.40 Uncomplicated

MENTAL DISORDERS DUE TO A GENERAL MEDICAL

CONDITION NOT ELSEWHERE CLASSIFIED
310.1 Personality Change Due to...
[Indicate the General Medical
Condition]

ALCOHOL-RELATED DISORDERS

303.90 Alcohol Dependence

305.00 Alcohol Abuse
291.8 Alcohol-Induced Mood Disorder
291.8 Alcohol-Induced Anxiety Disorder

AMPHETAMINE (OR AMPHETAMINE-LIKE)-RELATED

DISORDERS
304.40 Amphetamine Dependence
305.70 Amphetamine Abuse

COCAINE-RELATED DISORDERS
304.20 Cocaine Dependence
305.60 Cocaine Abuse

OPIOID-RELATED DISORDERS
304.00 Opioid Dependence
305.50 Opioid Abuse

SEDATIVE-, HYPNOTIC-, OR ANXIOLYTIC-RELATED

DISORDERS
304.10 Sedative, Hypnotic, or Anxiolytic Dependence
305.40 Sedative, Hypnotic, or Anxiolytic Abuse

POLYSUBSTANCE-RELATED
DISORDER
304.80 Polysubstance Dependence

SCHIZOPHRENIA AND OTHER PSYCHIATRIC

DISORDERS
295.xx Schizophrenia
.30 Paranoid Type
.10 Disorganized Type
.20 Catatonic Type
.90 Undifferentiated Type
.60 Residual Type
295.40 Schizophreniform Disorder
295.70 Schizoaffective Disorder
297.1 Delusional Disorder
298.8 Brief Psychotic Disorder
297.3 Shared Psychotic Disorder
293.xx Psychotic Disorder Due to...
.81 With Delusions
.82 With Hallucinations
298.9 Psychotic Disorder NOS

DEPRESSIVE DISORDERS
296.xx Major Depressive Disorder
.2x Single Episode
.3x Recurrent
300.4 Dysthymic Disorder
311 Depressive Disorder NOS

BIPOLAR DISORDERS
296.xx Bipolar I Disorder,
.0x Single Manic Episode
.40 Most Recent Episode Hypomanic
.4x Most Recent Episode Manic
.6x Most Recent Episode Mixed
.5x Most Recent Episode
Depressed
.7 Most Recent Episode Unspecified
296.89 Bipolar II Disorder
301.13 Cyclothymic Disorder
296.80 Bipolar Disorder NOS
293.83 Mood Disorder Due to...
[Indicate the General Medical Condition]

ANXIETY DISORDERS
300.01 Panic Disorder Without Agoraphobia
300.21 Panic Disorder With Agoraphobia
300.22 Agoraphobia Without History of Panic Disorder
300.29 Specific Phobia
300.23 Social Phobia
300.3 Obsessive-Compulsive Disorder
309.81 Posttraumatic Stress Disorder
308.3 Acute Stress Disorder
300.02 Generalized Anxiety Disorder

EATING DISORDERS
307.1 Anorexia Nervosa
307.51 Bulimia Nervosa
307.50 Eating Disorder NOS

ADJUSTMENT DISORDERS
309.xx Adjustment Disorder
.0 With Depressed Mood
.24 With Anxiety
.28 With Mixed Anxiety and Depressed Mood
.3 With Disturbance of Conduct
.4 With Mixed Disturbance of Emotions and
Conduct
.9 Unspecified
PERSONALITY DISORDERS
301.0 Paranoid Personality Disorder
301.20 Schizoid Personality Disorder
301.22 Schizotypal Personality Disorder
301.7 Antisocial Personality Disorder
301.83 Borderline Personality Disorder
301.50 Histrionic Personality Disorder
301.81 Narcissistic Personality Disorder
301.82 Avoidant Personality Disorder
301.6 Dependent Personality Disorder
301.4 Obsessive-Compulsive Personality Disorder
301.9 Personality Disorder NOS