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Nigeria "This book has really contributed to my knowledge on substance abuse and how to reduce it. South Sfrica "I am truly benefiting" — Khalifa. Somatic A person becomes falsely convinced that he or she has a bodily function disorder, for example, organ dysfunction, body odor, or parasite infection. Mixed A person is so diagnosed when no single delusional theme predominates. Unspecified A person is so diagnosed when a single delusional theme cannot be determined or when the predominant delusional theme does not match subtype criteria.
The delusions must be present for at least 1 month. Other than the delusion, the patient's social adjustment may be normal. The patient must not meet criteria for schizophrenia. Any mood disorder must be brief relative to the duration of the illness. The primary treatment is psychotherapy, P. Without such an alliance, most patients fall out of treatment; with an alliance, over time, the patient may relinquish the delusions. It can be temporally related to some stressor or occur postpartum, but it is also seen without any apparent antecedent.
ET IOLOGY Although the etiology is unknown, the disorder seems to be associated with borderline personality disorder and schizotypal personality disorder. Patients can exhibit any combination of delusions, hallucinations, disorganized speech, or grossly disorganized behavior.
Patients with the postpartum subtype typically develop symptoms within 1 to 2 weeks after delivery that resolve within 2 to 3 months. A mood disorder such as mania or depression with psychotic features must be ruled out.
Treatment with antipsychotics is common, although the condition is by definition self-limited, and no specific treatment is required. The containing environment of the hospital milieu may be sufficient to help the patient recover.
Schizophrenia is t reat ed wit h ant ipsychot ics and psychosocial support. I n schizoaffect ive disorder, t here are m ood dist urbances wit h psychot ic episodes and t here are periods of psychosis wit hout a m ood dist urbance. Schizoaffect ive disorder is t reat ed wit h ant ipsychot ics and m ood st abilizers. The prognosis for schizoaffect ive disorder is bet t er t han for schizophrenia but worse t han for a m ood disorder.
Schizophreniform disorder resem bles schizophrenia but resolves com plet ely in less t han 6 m ont hs schizophrenia or bipolar disorder m ost oft en result. Brief psychot ic disorder is charact erized by t ypical psychot ic sym pt om s last ing from 1 t o 30 days.
Brief psychot ic disorder can be preceded by a st ressor or can be post part um. Mood is a persistent emotional state as differentiated from affect, which is the external display of feelings.
There are three major categories of mood disorders according to the Di agnost i c and St at i st i cal Manual of Ment al Di sor der s, 4th edition DSM-IV : unipolar mood disorders major depressive disorder, dysthymic disorder , bipolar mood disorders bipolar I disorder, bipolar II disorder, and cyclothymic disorder , and mood disorders having a known etiology substance-induced mood disorder and mood disorder caused by a general medical condition Table The best available evidence suggests that mood disorders lie on a continuum with normal mood.
Although mania and depression are often viewed as opposite ends of the mood spectrum, they can occur simultaneously in a single individual within a brief period, giving rise to the concept of mixed mood states. It is now clear that, in addition to altered function in the hypothalamic-pituitary adrenal axis and in multiple neurotransmitter systems, that mood disorders are also associated with structural and functional brain alterations. Specific affected regions include the hippocampal formation, the amygdala, the cingulate gyrus anterior portions , and the prefrontal cortex especially dorsolateral prefrontal cortex.
White matter changes in the form of increased hyperintensities on magnetic resonance imaging also occur, most commonly in bipolar disorder type I.
Genetic factors are also emerging as increasingly important in influencing the risk for mood disorders. As an example, a genetic polymorphism producing reduced expression of the serotonin reuptake transporter has been associated with the risk for developing major depression when exposed to stressful life events. Figure depicts the major brain regions implicated in mood disorders. It is characterized by emotional changes, primarily depressed mood, and by so-called vegetative changes, consisting of alterations in sleep, appetite, and energy levels.
A major depressive episode can occur at any time from early childhood to old age. The female:male ratio is Race distributions appear equal, and socioeconomic variables do not seem to be a factor. The incidence rate of new cases is greatest between the ages of 20 and 40 and P. Approximately 2. In fact, available evidence suggests that childhood loss of a parent or loss of a spouse is associated with depression. Classic psychoanalytic theories center on ambivalence toward the lost object person , although more recent theories focus on the critical importance of the object relationship in maintaining psychic equilibrium and self-regard.
The cognitive-behavioral model views cognitive distortions as the primary events that foster a negative misperception of the world, which in turn, generate negative emotions. The learned helplessness model based on animal studies suggests that depression arises when individuals come to believe they have no control over the stresses and pains that beset them.
These symptoms must be a change from prior functioning and cannot be a result of a medical condition, cannot be substance-induced, and cannot be caused by bereavement. The symptoms must also cause di st r ess or i mpai r ment. Reproduced with permission from the American Psychiatric Association, Di agnost i c and St at i st i cal Manual of Ment al Di sor der s, 4th ed text revision.
Other affected regions of frontal lobe include medial superior frontal gyrus and not shown dorsolateral prefrontal cortex. Courtesy of Anatomical Chart Company. Biologic, familial, and genetic data support the idea of a biologic diathesis in the genesis of depression.
Unipolar depression in a parent leads to an increased incidence of both unipolar and bipolar mood disorders in their offspring. Neurotransmitter evidence points to abnormalities in amine neurotransmitters as mediators of depressive states: the evidence is strongest for deficiencies in norepinephrine and serotonin.
Neuroendocrine abnormalities in the hypothalamic-pituitary-adrenal axis are often present in depression and suggest a neuroendocrine link. Sleep disturbances are nearly universal complaints in depressed persons. Objective evidence from sleep studies reveals that deep sleep delta sleep, stages 3 and 4 is decreased in depression and that rapid eye movement REM sleep alterations include increased time spent in REM and earlier onset of REM in the sleep cycle decreased latency to REM.
Major depression is characterized by emotional and vegetative changes. Emotional changes most commonly include depressed mood with feelings of sadness, hopelessness, guilt, and despair.
Irritability may be the primary mood complaint in some cases. Vegetative symptoms include alterations in sleep, appetite, energy, and libido.
In addition to the symptoms seen in adults, children present with school avoidance, problems with authority, frequent headaches or stomachaches, and anger outbursts. Elderly persons, often beset by grief, loss, or medical illness, present with the usual adult symptoms and with higher rates of co-occurring anxiety.
Major depression is frequently recurrent. The usual duration of an untreated episode Fig. White men over age 65 have a suicide rate that is five times that of the general population.
Differential Diagnosis Mood disorders secondary to induced by medical illnesses or substance abuse are the primary differential diagnoses. Psychotic depression must be differentiated from schizophrenia; negative symptoms of schizophrenia can mimic depression. Persons with major depression may eventually meet criteria for bipolar disorder. A Major depressive disorder. B Dysthymic disorder. Milder cases may be treated with brief psychotherapy interventions alone.
For more severe cases, antidepressant medications combined with psychotherapy are superior to medications or psychotherapy alone. Among the psychotherapies, supportive, cognitive-behavioral, and brief interpersonal therapies have the most data to support their efficacy.
There is a long tradition of psychodynamic psychotherapy in treating depression, although it has not been well studied empirically. There are many classes of antidepressants available that are effective and are usually chosen according to side-effect profiles.
At present, available classes of antidepressants include tricyclic antidepressants, selective serotonin reuptake inhibitors, P. In addition, lithium, thyroid hormone, and psychostimulants may be used as augmentative treatments.
Children and adolescents with depression benefit from some antidepressants and from psychotherapy as well. They may be at higher risk of suicide during active pharmacologic treatment, and sufferers should be carefully followed by a mental health specialist. Elderly persons with depression do best when low dosages of antidepressants are initiated and raised slowly in conjunction with psychotherapy.
Electroconvulsive therapy ECT is used in psychotic, severe, or treatment-refractory depressions or when medications are contraindicated e.
Vagal nerve stimulation, a novel bioelectrical treatment involving the electrical stimulation of the vagus nerve via a surgically implanted device has shown some promise as a potential treatment for major depression, although current use is still limited by cost and availability.
Antipsychotic medications are an essential adjunct to antidepressants in psychotic depressions and may be helpful even in nonpsychotic depression.
Anxiolytics may be used as adjuncts to antidepressants in depression with high levels of anxiety, although moresedating antidepressants may suffice. Phototherapy can be used for seasonal mood disorders. ET IOLOGY Because dysthymia is often conceptualized as a milder, chronic form of major depression, similar etiologies are generally attributed to dysthymia.
The diagnosis of dysthymia requires that an individual experience a minimum of 2 years of chronically depressed mood most of the time Fig. Associated symptoms and complaints may include change in appetite and sleep, fatigue, decreased concentration, and hopelessness. Dysthymia can be chronic and difficult to treat. At times, major depressive episodes may co-occur, giving rise to the term doubl e depr essi on. Differential Diagnosis Major depression and etiologic mood disorders are the primary differential diagnostic considerations.
Patients with bipolar I disorder typically also experience major depressive episodes in the course of their lives. There are no racial variations in incidence. X linkage has been shown in some studies but remains controversial.
These symptoms must be a change from prior functioning and cannot be because of a medical condition and cannot be substance-induced. The symptoms must also cause distress or impairment. A single manic episode is sufficient to meet diagnostic requirements; most patients, however, have recurrent episodes of mania typically intermixed with depressive episodes. The criteria for a manic episode are outlined in Table The first episode of mania usually occurs in the early 20s. Manic episodes are typically briefer than depressive episodes.
The transition between mania and depression occurs without an intervening period of euthymia in about two of three patients Fig. Children can present with bipolar disorder that resembles the adult-type but differs according to age and developmental level. Very young children might present with uncontrollable giggling, slightly older children might try to teach their grammar school class in the presence of their teacher, and adolescents might present with severe anger outbursts and agitation.
Co-occurring psychiatric problems and psychosocial difficulties are the norm. Most children with bipolar disorder have more than one relative with the condition. A first episode of bipolar disorder in elderly individuals is rare. Medical or neurological causes of new bipolar disorder in an older person should be thoroughly investigated.
Differential Diagnosis Mania may be induced by antidepressant treatment, including antidepressant medications, psychostimulants, ECT, and phototherapy. When this occurs, the patient is diagnosed with substance- induced mood disorder, not bipolar disorder. Mood disorder caused by a general medical condition is the other major differential consideration. Schizoaffective disorder, borderline personality disorder, and depression with agitation are also considerations. Pharmacologic interventions for acute mania include antipsychotics in conjunction with benzodiazepines for rapid tranquilization and initiation of mood stabilizer medication.
Antipsychotics are frequently used in mania with and without psychotic features. Lithium is the most commonly used mood stabilizer, but valproic acid is quite effective and is more effective for the rapid-cycling variant of mania. Carbamazepine, lamotrigine, gabapentin, and long-acting benzodiazepines are used if first-line treatments fail. Some atypical antipsychotics, particularly clozapine, quetiapine, olanzapine, and aripiprazole, appear to act as mood stabilizers and are increasingly being used for maintenance of bipolar disorder.
ECT for mania, mixed episodes, or depressed episodes is used in patients with medication P. Combination medication therapy is more common than monotherapy, although studies on the safety and effectiveness of such combinations are lacking. Children and adolescents are treated with medications similar to those of adults, often in combination, but with even fewer studies backing up various treatment strategies. A Bipolar I disorder. B Bipolar II disorder. C Cyclothymic disorder.
Mood stabilizer maintenance therapy is essential in preventing the recurrence of mania and appears to decrease the recurrence of depression.
Care must be taken when prescribing antidepressants for depression or dysthymia because of their role in prompting more severe or more frequent manic episodes.
Bipolar II disorder may be more common in women. Hypomania is determined by the same symptom complex as mania, but the symptoms are less severe, cause less impairment, and usually do not require hospitalization.
Differential Diagnosis The differential diagnosis for bipolar II disorder is the same as for bipolar I disorder. Care must be taken in prescribing antidepressants for depression or dysthymia because of their role in prompting more severe or frequent hypomanic episodes. It is not diagnosed if a person has experienced either a manic episode or a major depressive episode.
The rate appears equal in men and women, although women more often seek treatment. A single episode of hypomania is sufficient to diagnose cyclothymic disorder; however, most individuals also have dysthymic periods. Cyclothymic disorder is never diagnosed when there is a history of mania or major depressive episode or mixed episode. The course of untreated cyclothymic disorder is depicted in Figure C.
Personality disorders especially borderline with labile mood may be confused with cyclothymic disorder. Persons with cyclothymia, however, may never seek medical attention for their mood symptoms. All the aforementioned types of mood disorder e.
Endocrine disorders, such as thyroid and adrenal dysfunction, are common etiologies. Postpartum mood disorders are excluded from the criteria; they are modifiers of unipolar and bipolar mood disorders. Subtypes and Modifiers Various diagnostic specifiers can be applied to specific subtypes of mood disorders.
These have prognostic and treatment implications and may prove to have etiologic implications. Melancholic: Melancholic depression is a severe form of depression associated with guilt, remorse, loss of pleasure, and extreme vegetative symptoms. Postpartum: Postpartum depression occurs within 4 weeks of childbirth.
The presence of one episode of postpartum mood disorder is strongly predictive of a recurrence. Seasonal: Seasonal mood disorders show a consistent seasonal pattern of variation. The most common pattern is a worsening of depression during the fall and winter with improvement in the spring.
The reverse is sometimes true. If the depression P. Atypical: Atypical depressions show a pattern of hypersomnia, increased appetite or weight gain, mood reactivity, long-standing rejection sensitivity, anergia, and leaden paralysis.
Rapid Cycling: Patients with bipolar disorder may have frequent rapid cycles. To meet criteria for rapid cycling, four mood disturbances per year must be present. The suicide rate may be higher than in nonrapid cyclers. Catatonic: The catatonic specifier is applied to mood disorders when there are pronounced movement abnormalities, including motoric immobility or excessive purposeless motor activity, maintenance of a rigid posture, mutism, stereotyped movement, echolalia repetition of a word or phrase just spoken by another person , and echopraxia repetition of movements made by another person.
Com bined psychot herapy and pharm acot herapy is t he best t reat m ent for m aj or depression. Dyst hym ia is a chronic unipolar m ood disorder last ing at least 2 years. Dyst hym ia is oft en refract ory t o t reat m ent. Bipolar I disorder requires m aint enance t reat m ent wit h m ood st abilizers; com binat ion t herapy is com m on. Cyclot hym ic disorder is a chronic, recurrent biphasic m ood disorder wit hout frank m ania or depression.
Anxiety can be adaptive or pathologic, transient or chronic, and has a variety of psychologic and physical manifestations. Anxiety disorders are a heterogeneous group of disorders in which the feeling of anxiety is the major element. They are the most prevalent group of psychiatric disorders; according to the Epidemiological Catchment Area study, 7. Anxiety disorders have strong associations with fear, and the amygdala is thought to play an important role in this regard.
Obsessive-compulsive disorder OCD has been linked to altered caudate and cingulate gyrus function. Regions of prefrontal cortex and hippocampus are also important. Table outlines diagnostic criteria for a panic attack. Agoraphobia is a disabling condition in which patients fear places from which escape might be difficult. Whether occurring as distinct disorders or together, panic disorder and agoraphobia are common, sometimes disabling, conditions. The typical onset is in the 20s, with most cases beginning before age Only one-third of patients with agoraphobia also have panic disorder.
Most patients with agoraphobia seen clinically also have panic disorder, however. This apparent contradiction is because patients with agoraphobia alone are unlikely to seek treatment. There are several popular biologic theories involving carbon dioxide hypersensitivity potentially involving medullary cholinergic function , abnormalities in lactate metabolism, an abnormality of the locus ceruleus a region in the brain that regulates level of arousal , and elevated central nervous system catecholamine P.
The GABA receptor has also been implicated as etiologic because patients respond well to benzodiazepines and because panic is induced in patients with anxiety disorders using GABA antagonists. Di agnost i c and St at i st i cal Manual of Ment al Di sor der s, 4th ed. Theorists posit that panic attacks are a conditioned response to a fearful situation. For example, a person has an automobile accident and experiences severe anxiety, including palpitations. Thereafter, palpitations alone, experienced during exercise or any sympathetic nervous system response, may induce the conditioned response of a panic attack.
Panic attacks typically come on suddenly, peak within minutes, and last 5 to 30 minutes. The patient must experience four of the 13 typical symptoms of panic outlined in Table Agoraphobia is a disabling complication of panic disorder but can also occur in patients with no history of panic disorder. It is characterized by an intense fear of places or situations in which escape might be difficult or embarrassing.
Patients with agoraphobia and panic disorder typically fear having a panic attack in a public place and being embarrassed or unable to escape.
Those with agoraphobia alone two- thirds of those with agoraphobia simply avoid public arenas but do not have panic attacks. Although some patients with agoraphobia are so disabled that they are homebound, many are comforted by the presence of a companion, allowing them to enter some public places with less anxiety.
Diagnostic Evaluation Panic disorder is diagnosed after taking a thorough history and performing necessary physical and laboratory examinations to rule out medical causes. In particular, cardiac conditions, such as rhythm disturbances, valvular abnormalities, and coronary artery disease, need to be carefully excluded. Use of psychostimulants P. Differential Diagnosis Panic attacks should be distinguished from the direct physiologic effects of a substance or a general medical condition particularly cardiac conditions or partial complex epilepsy.
The panic attacks also cannot be accounted for by another mental disorder, such as social phobia or OCD.
Specific tricyclic antidepressants, specific monoamine oxidase inhibitors MAOIs , selective serotonin reuptake inhibitors SSRIs , and highpotency benzodiazepines have been shown to be effective in controlled studies.
Cognitive-behavioral therapy CBT involves the use of relaxation exercises and desensitization combined with education aimed at helping patients to understand that their panic attacks are a result of misinterpreting bodily sensations.
Patients can then learn that the sensations are innocuous and self-limited, which diminishes the panicky response. Exposure therapy , in which the patient incrementally confronts a feared stimulus, has been shown to be effective in treating agoraphobia. It is the most common psychiatric disorder. DSM-IV identifies four category-specific subtypes of specific phobia and one general category: 1 animal type, 2 natural environment type, 3 blood-injection-injury type, 4 situational type, and 5 other type.
The typical onset is in childhood, with most cases occurring before age Behavioral theorists argue that phobias are learned by being paired with traumatic events. In addition, exposure to the stimulus must almost invariably provoke the anxiety reaction, and the avoidance of or distress over the feared situation must impair everyday activities or relationships. For those younger than age 18, symptoms must persist for at least 6 months.
When they persist into adulthood, they often become chronic; however, they rarely cause disability. Exposure therapy in the form of systematic desensitization or flooding is the treatment of choice. There is little role for medication. The disorder may be generalized or limited to specific situations.
The context criteria refer to circumstances in which one might have a medical condition e. If symptoms occur in most social situations, the social phobia is specified as generalized social phobia.
The typical onset is in adolescence, with most cases occurring before age Some theorists posit that hypersensitivity to rejection is a psychological antecedent of social phobia. Exposure to the feared social situation must almost invariably provoke an anxiety reaction. Avoidance of or distress over the feared situation must impair everyday activities or relationships.
Social phobia can either be generalized the patient fears nearly all situations or limited to specific situations. Differential Diagnosis The principal differential diagnosis is another mental disorder such as avoidance of school in separation anxiety disorder presenting with anxiety or fearfulness. SSRIs appear to be the most effective pharmacotherapy. CBT uses the exposure therapy techniques of flooding and P. Supportive individual and group psychotherapy is helpful to restore self-esteem and to encourage venturing into feared situations.
The associated symptoms highlight the physical and mental components of GAD. The context criteria mean that the focus of the anxiety is not about a symptom related to another Axis I condition for example, in panic disorder, excessive worry about having a panic attack would not be a symptom of GAD.
The typical age of onset is in the early 20s, but the disorder may begin at any age. Serotonergic, noradrenergic, and GABA-ergic neurotransmitter systems have been studied in relation to GAD, but the biologic etiology remains obscure. Cognitive-behavioral theorists posit that GAD is caused by cognitive distortions in which patients misperceive situations as dangerous when they are not. They do not have panic attacks, phobias, obsessions, or compulsions; rather, they experience pervasive anxiety and worry apprehensive expectation about a number of events or activities that occur most days for at least 6 months.
They must also have difficulty controlling the worry, and it must be associated with at least three of the following symptoms: restlessness, easily fatigued, difficulty concentrating or mind going blank, irritability, muscle tension, and sleep disturbance.
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