14

Psychiatric Disorders

I. Psychotic Disorders

A. Schizophrenia
1. Severe psychosis that causes significant limitations in functional ability; typically begins in late adolescence or early
adulthood
2. Risk factors = family history, maternal malnutrition, or illness during pregnancy; significantly higher rate in homeless
and indigent patients likely secondary to their inability to function in society due to the disease (“downward drift”)
3. Diagnosis requires presence of two or more symptoms (see a to e below) for at least 1 month within a 6-month period
and impaired social function for >6 months
a. Delusions (false beliefs about self or others which persist despite proof to the contrary)
b. Hallucinations (sensory perception in the absence of external stimuli; e.g., hearing voices, “seeing things”)
c. Disorganized thoughts or speech (e.g., circumstantiality, tangentiality, loose associations, “word salad,”
neologisms)
d. Disorganized or catatonic behavior
e. Negative symptoms (e.g., social withdrawal, flat affect, avolition, apathy, anhedonia, poverty of speech, “thought
blocking”)
4. Treatment
a. Antipsychotics (also known as neuroleptics) are the mainstay of therapy (see Table 14-1). Complications from
antipsychotics include neuroleptic malignant syndrome and serotonin syndrome, and need to be recognized and
distinguished from anticholinergic syndrome and malignant hyperthermia (see Table 14-2).
b. Psychotic exacerbations may require hospitalization.
c. Psychotherapy may be helpful in teaching the patient how to recognize symptoms.
5. Complications
a. Generally poor prognosis, with gradual deterioration over several years in ability to function in society.
b. Patients with predominantly negative symptoms and/or poor support systems have a worse prognosis.

Quick HIT
Functional ability generally refers to a patient’s ability to live independently, perform normal activities of daily living,
and function as a contributing member of society.

Quick HIT
High-potency antipsychotics have more extrapyramidal side effects and fewer anticholinergic side effects. Low-
potency antipsychotics have fewer extrapyramidal side effects and more anticholinergic side effects.
 Table 14-1 Antipsychotic Medications

Table 14-2 NMS Versus Serotonin Syndrome Versus Anticholinergic Toxidrome Versus Malignant
Hyperthermia

B. Other Psychotic Disorders

1. Schizophreniform disorder—psychosis characterized by at least two of the symptoms listed for schizophrenia, with a
duration of at least 1 month but fewer than 6 months
2. Brief psychotic disorder—psychosis characterized by at least one of the symptoms listed for schizophrenia (except
negative symptoms), with a duration of at least 1 day but less than 1 month
3. Delusional disorder—psychosis characterized by one or more delusions present for at least 1 month, but does not
meet the criteria for schizophrenia; no impairment of functioning apart from the ramifications of the delusion(s)
4. Schizoaffective disorder—psychosis characterized by at least two of the symptoms listed for schizophrenia
concurrent with a major depressive or manic episode; hallucinations or delusions must be present apart from the
mood episode

Quick HIT
Major depressive disorder (MDD) and mania may rarely cause psychosis, but the patient is never psychotic apart from
the mood episode. In schizoaffective disorder, the psychosis must be present apart from the mood symptoms.

II. Mood Disorders

A. Major Depressive Disorder (MDD)

1. Experience of significant depression that:
a. Lasts >2 weeks and impacts social and/or occupational function
b. Is not attributable to drug use or medical conditions
(1) Drugs that cause depressive symptoms include alcohol, benzodiazepines, antihistamines, traditional neuroleptics,
glucocorticoids, and interferon-α.
(2) Medical conditions that cause depressive symptoms include hypothyroidism, hyperparathyroidism, Parkinson
disease, stroke, and brain tumors.
2. Following resolution, depressive episodes have a 50% chance of recurring.
3. Pathology may be due to low serotonin, norepinephrine, and dopamine activity in the central nervous system (CNS).
4. Diagnosis requires presence of five of the following symptoms, including either depressed mood or anhedonia (i.e.,
loss of interest in previously pleasurable activity) lasting >2 weeks:
a. Depressed mood
b. Anhedonia
c. Change in sleep patterns (e.g., insomnia, hypersomnia)
d. Feelings of guilt/worthlessness
e. Fatigue
f. Inability to concentrate
g. Changes in appetite or weight
h. Psychomotor retardation or agitation (i.e., impaired motor ability related to mental state)
i. Thoughts about death (suicidal ideation)

NEXT
STEP
Tardive dyskinesia is a complication of antipsychotic medications characterized by repetitive facial movements
(e.g., chewing, lip smacking) beginning after several months of therapy. It should be treated by stopping the
offending drug if the patient’s condition allows, but it may be irreversible.

NEXT
STEP
Neuroleptic malignant syndrome is:
An uncommon complication of antipsychotic medications that starts within days of usage and carries a high
mortality rate.
Characterized by “FEVER”: Fever, Encephalopathy, Vitals unstable, Elevated enzymes (CPK), Rigidity of
muscles.
Treated by immediately stopping the drug, giving antipyretics, correcting electrolytes abnormalities, and
administering a dopamine agonist such as dantrolene.

5. Subtypes of MDD
a. MDD with atypical features is major depression characterized by:
(1) Mood reactivity
(2) Hyperphagia (increased appetite and weight gain)
(3) Hypersomnia
(4) Psychomotor retardation (“leaden paralysis”)
(5) Hypersensitivity to rejection is common
 b. MDD with seasonal pattern is depression that occurs in a regular pattern corresponding to certain seasons, usually
fall and winter, due to decreased exposure to sunlight. Treat with phototherapy.
c. MDD with peripartum onset is depression that begins during pregnancy or within 4 weeks of delivery.
d. MDD with psychotic features is depression associated with delusions, hallucinations, or other psychotic symptoms.
6. Treatment
a. Psychotherapy (i.e., cognitive or behavioral counseling and instruction designed to provide insight into condition and
modify behavior)
b. Pharmacologic therapy (may be combined with psychotherapy) (see Table 14-3)
c. Electroconvulsive therapy (ECT) can be used for refractory or severe cases to decrease frequency of major
depressive episodes

Quick HIT
MDD with atypical features is the most common subtype of major depression.

B. Persistent Depressive Disorder

1. Symptoms of depression on more days than not for >2 years. May include:
a. Chronic major depression
b. Chronic mild depression that does not meet the criteria for MDD
2. H/P = diagnosis requires dysphoria (depressed mood) plus at least two other depressive symptoms for most days for
>2 years
3. Treatment = pharmacotherapy with or without psychotherapy

MNEMONIC
Remember the characteristics of manic episodes by the mnemonic DIG FAST:
Distractibility
Insomnia
Grandiosity
Flight of ideas
Activity (goal-oriented)
Pressured Speech
Taking risks/Thoughtlessness

C. Bipolar Disorder
1. Cyclic episodes of depression and mania (or hypomania) that impair the patient’s ability to function; patient is able to
function normally between episodes
 Table 14-3 Antidepressant Medications

a. Manic episode
(1) Elevated, expansive, or irritable mood lasting at least 1 week
(2) Three or more of the following symptoms: grandiosity, pressured speech, decreased need for sleep, flight of
ideas, easy distractibility, increased goal-oriented activity, increased risky pleasurable activity
(3) Episodes cause significant impairment of ability to function
b. Hypomanic episode
(1) Elevated, expansive, or irritable mood lasting at least 4 days
(2) Three or more of the symptoms of mania (see above)
(3) Episode does not cause significant impairment of ability to function
2. Types
a. Bipolar I: at least one manic episode; episodes of major depressive are common but are not required for the
diagnosis
b. Bipolar II: at least one hypomanic episode and at least one major depressive episode
c. When present, depressive episodes are identical to those seen with MDD
3. Treatment
a. Patients should be hospitalized if psychotic or judged to be a risk to themselves or others until they can be stabilized.
b. Mood stabilizers (e.g., lithium, valproate, lamotrigine, carbamazepine), which may be used alone or in combination
with atypical antipsychotics (e.g., aripiprazole, quetiapine, risperidone), are used to control and prevent manic and
 hypomanic episodes and to treat depression.
c. Lithium is frequently the first-line drug for long-term treatment of mania.
(1) Mechanism is unknown but likely involves inositol triphosphate activity.
(2) Adverse effects include tremor, nephrogenic diabetes insipidus, hypothyroidism, teratogenesis (Ebstein anomaly),
renal insufficiency, weight gain.

NEXT
STEP
A history of mania must be ruled out by a thorough history in a patient suspected of having MDD before antidepressants
are prescribed. Antidepressants given to a patient with bipolar disorder who is not taking mood stabilizers can induce
a manic episode.

D. Cyclothymic Disorder
1. Rapid cycling of mild manic symptoms and mild depression lasting >2 years without a period of normal mood >2 months
2. Mood symptoms impair the ability to function, but criteria for major depression, mania, or hypomania are not met
3. Treatment = psychotherapy or mood stabilizers

III. Anxiety Disorders

A. Panic Disorder
1. Experience of recurrent, spontaneous panic attacks with associated fear that these episodes will occur; typically begins
in late adolescence.
2. H/P
a. Recurrent, unexpected panic attacks that last up to 30 minutes and consist of extreme anxiety, feelings of
impending danger, chest pain, shortness of breath, palpitations, diaphoresis, nausea, dizziness, paresthesias, chills
or hot flashes, fear of losing control, or fear of dying.
b. Diagnosis requires a history of recurrent episodes plus a persistent fear that attacks will happen again, or
maladaptive change of behavior designed to avoid the attacks.
3. Treatment
a. Cognitive behavioral therapy may help alleviate fear between attacks and decrease panic attack occurrence.
b. Selective serotonin–reuptake inhibitors (SSRIs) and serotonin–norepinephrine reuptake inhibitors (SNRIs) are used
for long-term therapy in patients with frequent attacks.
c. Benzodiazepines can be used to break acute attacks (see Table 14-4).

Table 14-4 Anxiolytic Medications

B. Generalized Anxiety Disorder

1. Excessive, persistent anxiety and worry that occur more days than not for >6 months and impairs ability to function.

Quick HIT
It is very difficult to commit suicide using an overdose of benzodiazepines because their lethal dose is >1,000 times
the therapeutic dose. Flumazenil is a benzodiazepine antagonist that can reverse the effects of an overdose.

2. Epidemiology = women twice as likely affected than men. Typically begins in early adulthood.
3. H/P
a. Diagnosis requires excessive anxiety for most days, impairment of ability to function, and three of the symptoms listed
below for >6 months.
 b. Symptoms include restlessness or feeling “on edge,” fatigue, inability to concentrate, irritability, muscle tension, sleep
disturbance.
4. Treatment = cognitive behavioral therapy; SSRIs or SNRIs; buspirone is considered safer for long-term therapy than
benzodiazepines (see Table 14-4) because of the chronic nature of the anxiety and the risk of benzodiazepine
dependence.

C. Social Anxiety Disorder

1. Excessive fear or anxiety about social situations in which the individual is exposed to scrutiny by others, which is out
of proportion to the actual threat that the social situation poses
2. H/P = social situations (e.g., performances, conversations) cause anxiety that can be mild or severe (i.e., panic attacks);
patients avoid these situations and have a persistent fear of being embarrassed
3. Treatment
a. Cognitive behavioral therapy.
b. β-Blockers can be used in mild cases to prevent tachycardia when engaging in an anxiety-provoking situation.
c. SSRIs frequently are effective at reducing anxiety and permitting social interactions.
d. Benzodiazepines are an alternative option for reducing acute anxiety.

D. Specific Phobia
1. Fear of a particular object, activity, or situation that causes the patient to avoid feared subject; typically begins in
childhood
2. H/P = encountering feared subject incites panic attack, the patient makes great effort to avoid feared subject and
realizes that behavior is irrational; some patients may experience vasovagal response (i.e., fainting) during episodes
3. Treatment = psychotherapy involving systematic desensitization through repeated exposure, relaxation techniques,
hypnosis, or insight modification

IV. Obsessive-Compulsive and Related Disorders

A. Obsessive-Compulsive Disorder (OCD)

1. Presence of obsessions and/or compulsions that cause impairment in function and affect daily life. Patients have
varying degrees of insight into their condition. Associated comorbidities include mood disorders (∼70%), obsessive
compulsive personality disorder, and tics (∼30%).
a. Obsessions are recurrent, persistent thoughts or urges that are intrusive and unwanted and that cause anxiety or
distress.
b. Compulsions are repetitive, ritualized behaviors (e.g., hand-washing), or mental acts (e.g., reciting specific words,
counting) that are aimed at reducing or preventing the anxiety or distress caused by obsessive thoughts. Resisting
the urge to engage in these compulsions results in increased anxiety.

Quick HIT
OCD is distinct from obsessive- compulsive personality disorder (OCPD). For OCD patients the obsessions and
compulsions are unwanted and distressing (ego-DYStonic). For OCPD, the behaviors are perceived desirable, as
they have to do with control and perfectionism (ego-SYNtonic).

2. H/P
a. Diagnosis requires presence of obsessions or compulsions that significantly affect daily life.
b. Stressful events can exacerbate compulsive behaviors.
c. Patients are aware of compulsive behaviors but feel unable to control them.

Quick HIT
OCD has a significant genetic component, with mean age of onset at age 20 and equal prevalence in men and
women.

3. Treatment = cognitive behavioral therapy and pharmacologic therapy (SSRIs, SNRIs) help limit and control behavior.
Patients often seek help for the consequences of their OCD such as chafed hands from excessive handwashing.

B. Body Dysmorphic Disorder

1. Preoccupation with a perceived defect in physical appearance that limits ability to function; typically begins in
adolescence
2. Patient performs repetitive behaviors (e.g., mirror checking, excessive grooming) related to the concerns about his or
her appearance
3. Higher prevalence in survivors of child abuse, first-degree relatives of patients with OCD, and in cosmetic surgery
patients
4. H/P = patient imagines physical defect in distinct body region, frequently presents to dermatologist or plastic surgeon to
“improve” defect, and continues to imagine defect following treatment
5. Treatment
a. Psychotherapy addressing self-perception
b. Antidepressants may help in refractory cases
c. Avoid performing needless surgery

C. Hoarding Disorder
1. Patient has difficulty discarding or parting with possessions, even if they have no real value; discarding possessions
results in significant distress.
2. Accumulation of possessions results in excessive clutter and potentially dangerous/unhealthy living conditions.
3. Treatment = cognitive behavioral therapy targeted at hoarding. Generally very difficult to treat.

V. Stress- and Trauma-Related Disorders

A. Adjustment Disorder
1. Behavioral and emotional symptoms in response to a specific stressful event or situation (e.g., death in family,
assault, divorce), occurring within 3 months of the event and causing significant impairment of ability to function
2. H/P
a. Distress out of proportion of what is expected following a stressful event, inability to concentrate, self-isolation,
change in sleep patterns, change in appetite.
b. May be characterized as adjustment disorder with depressed mood, with anxiety, with mixed anxiety and depressed
mood, with disturbance of conduct, etc.
c. Symptoms begin within 3 months of stressful event and end 6 months after end of stressor.
3. Treatment = cognitive behavioral therapy; antidepressants or anxiolytics can be used if psychotherapy alone is unable
to effect normal daily functioning

Quick HIT
Acute stress disorder starts within 1 month of the trigger event and resolves within 1 month. Adjustment disorder starts
within 3 months of trigger event and resolves within 6 months.

B. Posttraumatic Stress Disorder (PTSD)

1. Complex syndrome of symptoms that occurs following psychological trauma (exposure to actual or threatened death,
serious injury, or sexual violation)
a. The event can be directly experienced by the patient, witnessed in person, or experienced by a close family member
or friend.
b. Symptoms typically begin within a few months of the event, and must last at least 1 month.
2. H/P
a. Intrusion symptoms in which the individual reexperiences the traumatic event (e.g., intrusive memories; recurrent,
distressing dreams; flashbacks; psychological distress; or physiologic reactions to internal or external cues that
resemble the event)
b. Avoidance of activities or settings associated with the event
c. Persistent negative alterations in cognition or mood associated with the event (e.g., amnesia of certain aspects of
the event, exaggerated negative beliefs about self or others, blaming self for the event, anhedonia, feelings of
detachment, increased state of arousal, survivor guilt, social withdrawal)
3. Treatment = cognitive behavioral therapy, alone or in combination with SSRI or SNRI; atypical antipsychotics may be
beneficial for symptoms refractory to SSRIs or SNRIs. Prazosin, an α-1 receptor antagonist, is helpful to decrease
nightmares and hypervigilance

VI. Somatic Symptom and Related Disorders

A. Conversion Disorder
1. Also known as functional neurologic symptom disorder.
2. Development of sensory or voluntary motor deficits without a recognized medical or neurologic condition to cause
the deficits. Onset is abrupt.
3. H/P = symptoms may include weakness/paralysis, tremor, dystonia, gait disturbance, dysphagia, dysphonia/dysarthria,
seizures, numbness/paresthesias, visual or hearing disturbance, or any combination thereof.
4. Treatment = Simply presenting the diagnosis and educating the patient about the psychogenic nature of the deficit may
lead to spontaneous resolution of symptoms in 40% to 50% of cases; second-line treatments include cognitive
behavioral therapy and physical therapy; SSRIs and SNRIs are sometimes helpful.
Quick HIT
“La belle indifference” a French phrase for “beautiful indifference” is characteristic of conversion disorder. Patients are
seemingly aloof to their loss of function or neurologic symptom.

Quick HIT
Malingering is the falsification of disease in order to obtain some benefit or reward, such as being excused from work
or school, obtaining narcotics, pursuing legal action, etc. More common in men.

B. Somatic Symptom Disorder

1. One or more somatic symptoms which may or may not be due to a recognized medical condition, but which are
distressing or disruptively to daily life; accompanied by anxiety about health and persistent worry about the
seriousness of the symptoms. Patients have a tendency to “doctor-shop” resulting unnecessary diagnostic testing and
medical procedures.
2. While the specific symptoms may change over time, the worry and impaired psychosocial functioning are persistent,
lasts >6 months.
3. H/P = somatic symptoms may include:
a. Pain symptoms
b. Sexual symptoms (e.g., erectile dysfunction, decreased libido)
c. Neurologic symptoms
d. Gastrointestinal symptoms (e.g., vomiting, diarrhea)
4. Treatment = tricyclic antidepressants (TCAs) and SSRIs are beneficial, as is cognitive behavioral therapy. Set patient
up with a single primary care doctor.

Quick HIT
In contrast to patients with conversion disorder, patients with somatic symptom disorder are very distressed by their
health symptoms.

C. Illness Anxiety Disorder

1. Preoccupation with having or acquiring a serious illness in the absence of significant somatic symptoms,
accompanied by:
a. A high level of anxiety about health
b. Performance of excessive health-related behaviors (such as repeatedly checking for evidence of a serious illness)
2. Treatment
a. Regular physician visits help to alleviate fears.
b. Cognitive behavioral therapy and SSRIs are beneficial.

NEXT
STEP
Münchausen syndrome by proxy is a disorder in which parents try to make their children appear to have a certain
disease. It is considered child abuse and must be reported to the appropriate authorities.

D. Factitious Disorder (Münchausen Syndrome)

1. Falsification of physical or psychological signs or symptoms of a disease or injury in the absence of obvious reward or
clear benefit to the patient
2. H/P
a. Patient reports symptoms or signs of a given disease and attempts to induce disease process (e.g., self-injections of
insulin or excrement, attempts to become infected by a pathogen, induction of vomiting/diarrhea, etc.)
b. Patient may deny intentional production of symptoms; may wander from one physician to another
3. Treatment
a. Patient denial makes treatment difficult.
b. No unnecessary therapies should be administered.
c. Attempt to limit medical care to one physician and one hospital.
d. If patient is willing, psychotherapy may be beneficial.

Quick HIT
The difference between factitious disorder and malingering is that there is no clear benefit or secondary gain for the
patient in factitious disorder.
 VII. Eating Disorders

A. Anorexia Nervosa
1. Eating disorder characterized by:
a. Distorted body image (patients believe that they are overweight)
b. Intense fear of gaining weight
c. Reduced caloric intake relative to energy requirements and refusal to maintain a normal body weight; may
involve fasting, excessive exercise, purging, etc.
2. Risk factors = adolescence, high socioeconomic status; 90% of cases are women
3. H/P = low body weight (generally <85% ideal body weight), fixation on prevention of weight gain, severe body image
disturbance, amenorrhea, cold intolerance, hypothermia, dry skin, lanugo hair growth (i.e., fine, short hair similar to that
in the newborn), bradycardia. Osteoporosis may be present. Patients often have comorbid depression
4. Treatment
a. Inpatient treatment is frequently required to aid in weight gain.
b. Psychotherapy that focuses on body image, weight gain; sufficient caloric intake is needed to maintain long-term
control.
c. Pharmacologic therapy has not been proved beneficial.
5. Complications = electrolyte abnormalities, arrhythmias (especially ventricular types), refeeding syndrome

NEXT
STEP
Patients with anorexia nervosa should be screened for depression, and SSRIs should be included in treatment if
depression is diagnosed.

Quick HIT
Anorexia nervosa carries a 6% 10-year mortality rate caused by disease complications or suicide.

Quick HIT
Refeeding syndrome results from the sudden shift from fat to carbohydrate metabolism in severe anorexics who
resume eating and is characterized by hypophosphatemia, hypomagnesemia, and hypocalcemia. Complications
can include cardiovascular collapse, rhabdomyolysis, confusion, and seizures.

B. Bulimia Nervosa
1. Eating disorder characterized by:
a. Binge eating (inappropriate high caloric intake within a short period of time, which the patient often perceives as
uncontrollable)
b. Inappropriate compensatory behaviors (e.g., purging, strict caloric restriction, excessive exercise) following binges,
to prevent weight gain
c. Unhealthy preoccupation with weight and body shape; these patients generally maintain a normal (not low) body
weight
2. H/P
a. Bingeing–compensation episodes occur at least once a week for >3 months.
b. Physical examination may reveal dental enamel erosion (from repeated vomiting), scars on hands (from inducing
vomiting), parotid enlargement/inflammation (which may elevate serum amylase), and oligomenorrhea.
3. Treatment = nutritional counseling; psychotherapy (cognitive behavioral therapy) directed at body image and reduction
of bingeing–compensation cycles; SSRIs or TCAs help in behavior modification. FDA-approved medication for bulimia
is Fluoxetine.

C. Binge Eating Disorder

1. Eating disorder characterized by uncontrollable episodes of binge eating without inappropriate compensatory
behaviors.
a. On average, binges occur at least once a week for >3 months.
b. Patients are often overweight or obese due to excessive caloric intake.
2. Treatment = psychotherapy (cognitive behavioral therapy and intrapersonal therapy) is first line and is generally more
effective than pharmacotherapy; SSRIs may be used.

VIII. Personality Disorders

A. Persistent pattern of inner experience and behavior that deviates significantly from cultural norms
1. Manifested through perception of others, affect, interpersonal relationships, and impulse control
2. Is persistent and inflexible despite situation
3. Leads to impaired ability to function
4. Typically begins in late adolescence
5. Is not attributable to drug use, medical condition, or other psychiatric disorder
6. Generally difficult to treat as patients have no insight or awareness that they need help

Quick HIT
A patient who exhibits mild signs of a personality disorder but is able to function normally in society is said to have a
personality trait and may not require treatment.

B. Clusters (See Table 14-5)

1. Classification system of personality disorders:
a. Cluster A: odd or eccentric (“weird”). Includes schizoid, schizotypal, and paranoid.
b. Cluster B: dramatic or emotional (“wild”). Includes histrionic, narcissistic, borderline, and antisocial.
c. Cluster C: anxious or fearful (“wimpy or worried”). Includes avoidant, dependent, and obsessive compulsive.
2. Personality disorders not meeting criteria for any of the defined variants are classified as “personality disorder not
otherwise specified (NOS).”
 Table 14-5 Personality Disorders
Disorder Characteristics Treatment
Cluster A

Paranoid Persistent distrust and suspicion of others, others’ actions consistently Supportive, nonjudgmental psychotherapy, low-dose
interpreted as harmful or deceptive, reluctant to share information, frequent antipsychotics
misinterpretation of comments, frequent angry reactions, common suspicions of
partner fidelity

Schizoid Inability to form close relationships, social detachment, emotionally restricted, Antipsychotics initially to resolve behavior, supportive
anhedonia, flat affect, lack of sexual interests psychotherapy focusing on achieving comfortable
interactions with others

Schizotypal Paranoia, ideas of reference, eccentric and inappropriate behavior, social Supportive psychotherapy focusing on recognition of
anxiety, disorganized speech, odd beliefs reality, low-dose antipsychotics or anxiolytics

Cluster B

Antisocial Aggressive behavior toward people and animals, destruction of property, illegal Structured environment, psychotherapy with defined
activity, pathologic lying, irritability, risk-taking behavior, lack of responsibility, limit-setting may be helpful in controlling behavior
lack of remorse for actions; patient >18 yrs of age, history of conduct disorder
prior to 15 yrs of age; more common in men

Borderline Unstable relationships, feelings of emptiness, fear of abandonment, poor self- Extensive psychotherapy using multiple techniques
esteem, impulsivity, mood lability, suicidal ideation, inappropriate irritability, combined with low-dose antipsychotics, SSRIs, or
paranoia, splitting (seeing others as either all good or all bad); much more mood stabilizers
common in women

Histrionic Attention-seeking, inappropriate seductive or theatrical behavior, emotional Long-term psychotherapy focusing on relationship
lability, shallow relationships, dramatic speech, uses appearance to draw development and limit-setting
attention to self, easily influenced by others, believes relationships more
intimate than they are

Narcissistic Grandiosity, fantasies of success, manipulation of others, expectation of Psychotherapy focusing on acceptance of
admiration, arrogance, sense of entitlement, believes self to be “special,” lacks shortcomings
empathy, envious of others

Cluster C

Avoidant Fear of criticism and embarrassment, social withdrawal, fear of intimacy, poor Psychotherapy (initially individualized, then group
self-esteem, reluctance to try new activities, preoccupied by fear of rejection, therapy later) focusing on self-confidence combined
inhibited by feelings of inadequacy with antidepressants or anxiolytics

Dependent Difficulty making decisions, fear of responsibility, difficulty expressing Psychotherapy focusing on developing social skills and
disagreement, lack of confidence in judgment, need for others’ support, fear of development of decisive behavior
being alone, requires constant close relationships

Obsessive compulsive Preoccupied with details, perfectionistic, excessively devoted to work, inflexible Psychotherapy focusing on accepting alternative ideas
in beliefs, miserly, difficulty working with others, hoarding of worthless objects, and working with others
stubbornness

SSRIs, selective serotonin–reuptake inhibitors.

IX. Substance Abuse

A. Substance use disorder: problematic substance (e.g., alcohol, drug) use that results in significant functional
impairment or stress; formerly labeled “substance abuse” or “substance dependence”; symptoms may include:
1. Consumption of larger amounts of the substance than intended
2. Significant energy spent obtaining, using, or recovering from the substance
3. Tolerance
4. Cravings
5. Persistent desire or unsuccessful attempts to quit or cut down on substance use

NEXT
STEP
Use the CAGE questionnaire to screen for alcohol abuse. More than one “yes” response to any of these conditions
should raise suspicion for excessive use:
Desire to Cut down on usage
Annoyance over others’ suggestions to stop usage
Guilt over usage
Drug use on waking (i.e., Eye-opener)
B. Intoxication: reversible CNS effect of a substance following usage (see Table 14-6)
C. Physical dependence: physical adaptation to repetitive substance use in which abrupt cessation or antagonist use
causes a withdrawal syndrome (see Table 14-6)
D. Psychological dependence: perceived need for a given substance because of its associated positive effects or because
of fear of effects from lack of use
E. Patients who successfully change habits or behaviors frequently progress through the following stages of change:
1. Precontemplation—no acknowledgment that a problem exists or that a change needs to be made (i.e., denial)
2. Contemplation—admitting the need to change at some unspecified point in the future, but no immediate plans for
change
3. Preparation—making concrete plans to deal with problem
4. Action—implementing changes
5. Maintenance—making sure changes are continued
Table 14-6 Characteristics of Substance Abuse
QUESTIONS