Psychiatry 1

• BN: Prozac
• Class: SSRI, Antidepressant

• BN: Celexa
• Class: SSRI, Antidepressant

• BN: Lexapro
• Class: SSRI, Antidepressant

• BN: Paxil
• Class: SSRI, Antidepressant

• BN: Zoloft
• Class: SSRI, Antidepressant

• BN: Effexor
• Class: Serotonin (5-HT)-NE Reuptake Inhibitor (SNRI), Antidepressant

• BN: Pristiq
• Class: SNRI, Antidepressant

• BN: Cymbalta
• Class: SNRI, Antidepressant

• BN: Remeron
• Class: NE-5-HT Reuptake Inhibitor, presynaptic α2 antagonist, Antidepressant

• BN: Budeprion, Wellbutrin
• Class: Dopamine- Norepinephrine (NE) Reuptake Blocker, Antidepressant

• BN: Nardil
• Class: MAO Inhibitor, Antidepressant

• BN: Parnate
• Class: MAO Inhibitor, Antidepressant

• BN: Emsam
• Class: MAO Inhibitor (transdermal), Antidepressant

• BN: Pamelor
• Class: Tricyclic antidepressant (TCA), Antidepressant

• BN: Haldol
• Class: Butyrophenone, Antipsychotics

• BN: Abilify
• Class: Atypical Antipsychotic

• BN: Clozaril
• Class: Atypical Antipsychotic

• BN: Zyprexa
• Class: Atypical Antipsychotic

• BN: Seroquel
• Class: Atypical Antipsychotic

• BN: Risperdal
• Class: Atypical Antipsychotic

• BN: Geodon
• Class: Atypical Antipsychotic

• BN: Tegretol
• Class: Antiepileptic, Mood stabilizer

• BN: Depakene
• Class: Antiepileptic, Mood stabilizer

• BN: Depakote
• Class: Antiepileptic, Mood stabilizer

• BN: Buspar
• Class: 5-HT partial agonist, Anxiolytic

• BN: Xanax
• Class: Benzodiazepine, Anxiolytic

• BN: Klonopin
• Class: Benzodiazepine, Anxiolytic

• Clomipramine
• BN: Anafranil
• Class: TCA, Anxiolytic

• Fluoxetine: Prozac
• Citalopram: Celexa
• Escitalopram: Lexapro
• Paroxetine: Paxil
• Sertraline: Zoloft

• Venlafaxine: Effexor
• Desvenlafaxine: Pristiq
• Duloxetine: Cymbalta

Mirtazapine: Remeron

Bupropion: Budeprion, Wellbutrin

• Phenelzine: Nardil
• Tranylcypromine: Parnate
• Selegiline: Emsam (transdermal)

Nortriptyline: Pamelor

Haloperidol: Haldol

• Aripiprazole: Abilify
• Clozapine: Clozaril
• Olanzapine: Zyprexa
• Quetiapine: Seroquel
• Risperidone: Risperdal
• Ziprasidone: Geodon

• Carbamazepine: Tegretol
• Valproic acid: Depakene
• Divalproex sodium: Depakote

Buspirone: Buspar

• Alprazolam: Xanax
• Clonazepam: Klonopin

Clomipramine: Anafranil

• Medical specialty devoted to the study and treatment of mental illnesses;
• “Study” of the “Mind”
• Term coined in 1808 by German physician Johann Reil

Term refers to a wide range of mental health conditions and disorders that affect mood, cognition, and behavior.

There is no specific identifiable cause of mental illness. Mental illnesses are thought to be caused by a variety of genetic and environmental factors. Risk factors have been identified for many disorders

Based on stereotypes, stigma is a negative judgment based on a personal trait — in this case, having a mental health condition. It was once a common perception that having a mental illness was due to some kind of personal weakness.

• Get treatment
• Don’t let stigma create self-doubt and shame
• Seek support
• Don’t equate yourself with your illness
• Use your resources
• Join an advocacy group
• Speak out

• 1812: Benjamin Rush, M.D. (1745-1813), signer of the Declaration of Independence and the Father of American Psychiatry, published the first psychiatric textbook in the United States, Inquiries and Observations on Diseases of the Mind.
• 1829: Dorothea Dix (1802-1887), a Boston school teacher, visited a jail and found insane people confined there under inhumane conditions. For the next fifty years she successfully involved prominent people to persuade state legislatures to appropriate funds to build mental hospitals. More than 32 state hospitals are credited to her efforts.
• 1844: The first psychiatric journal, The American Journal of Insanity, was published in June by Amariah Brigham, Superintendent of the Utica (NY) State Hospital.
• 1851: The Association adopted propositions proposed by Thomas Kirkbride, M.D., Superintendent of the Pennsylvania Hospital for the Insane, for the design and organization of mental hospitals. These policies dictated the architecture of state hospitals for over fifty years.
• 1902: A psychiatric unit was established in the Albany (NY) General Hospital.
• 1906: The University of Michigan established a psychiatric hospital for research, training and treatment. Similar hospitals followed.
• 1909: Sigmund Freud (1856-1939) of Vienna was invited to lecture at Clark University (MA). His new theories and treatment approaches were adopted by prominent psychiatrists. Psychoanalysis became a leading therapy throughout the 20th Century in the U.S.
• 1917: World War I produced numerous psychiatric casualties. Thomas Salmon (1876-1927), Medical Director of the National Committee for Mental Hygiene, became chief psychiatrist of the Army overseas and introduced successful treatment methods which were used in succeeding wars.
• 1930s: The decade saw the introduction of somatic therapies in psychiatry, including insulin, Metrazol, and electroconvulsive therapy.
• 1946: The APA established the first standards for psychiatric hospitals and outpatient clinics. Congress passed the National Mental Health Act establishing the National Institute for Mental Health and, for the first time, provided Federal funds for research into mental disorders, training for mental health professionals, and community psychiatric services.
• 1955: Psychoactive drugs were introduced in the U.S. and widespread use led to increased discharges from mental hospitals.
• 1963: Congress passed the National Community Mental Health and Retardation Act to provide federal funds for construction of facilities followed in 1965 with appropriations for staffing. Subsequent legislation authorized the National Institute on Alcohol Abuse and Alcoholism and the National Institute on Drug Abuse.
• 1990s: Research produced new information on the structure and function of the brain through advances in genetics, imaging techniques, and chemistry, which improved diagnosis and treatment of psychiatric disorders.
• 2008: Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA)
• “The rules we are issuing today will, for the first time, help assure that those diagnosed with these debilitating and sometimes life-threatening disorders will not suffer needless or arbitrary limits on their care.”

• This model posits that physical processes, such as the pathology, the biochemistry, and the physiology of a disease, are the primary determinants of health.
• “Traditional” model developed in the mid-1800s

• This model posits that biological , psychological (which entails thoughts, emotions, and behaviors), and social factors, all play a significant role in human functioning in the context of disease or illness.
• Model was theorized by Psychiatrist George Engel at the University of Rochester in the journal Science (1977)

“A categorical classification that divides mental disorders into types based on criteria sets with defining features.”

• 1840: Census - category for “idiocy/insanity”
• 1880: Census - 7 distinguished categories
• 1917: Census – statistics obtained from mental hospitals
• 1940s: Broader nomenclature developed by the U.S. Army during World War II
• 1948: ICD-6 included 26 categories and was heavily influenced by the Veterans Administration nomenclature
• 1952: DSM-I (106 D/Os). The first official manual to focus on clinical utility. Supported the notion that mental disorders represented reactions of the personality to psychological, social, and biological factors.
• 1968: DSM-II (182 D/Os)
• 1980: DSM-III (265 D/Os)
• 1987: DSM-III-TR (292 D/Os)
• 1994: DSM-IV (297 D/Os)
• 2000: DSM-IV-TR (297 D/Os)
• Prior diagnoses that have been removed include: Reaction, Neuroses, Sexual Orientation Disturbance

• It is intended to be applicable in a wide array of contexts and used by clinicians and researchers of many different orientations (e.g., biological, psychodynamic, cognitive, behavioral, interpersonal, family/systems).
• Designed for use across clinical settings (inpatient, outpatient, partial hospital, consultation-liaison, clinic, private practice, and primary care), with community populations.
• It can be used by a wide range of health and mental health professionals, including psychiatrists and other physicians, psychologists, social workers, nurses, occupational and rehabilitation therapists, and counselors.
• It is also a necessary tool for collecting and communicating accurate public health statistics.
• Content provided from 13 workgroups with members participating as consensus scholars who followed a formal evidence-based process

• Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence
• Delirium, Dementia, and Amnestic and Other Cognitive Disorders
• Mental Disorders Due to a General Medical Condition
• Substance-Related Disorders
• Schizophrenia and Other Psychotic Disorders
• Mood Disorders
• Anxiety Disorders
• Somatoform Disorders
• Factitious Disorders
• Dissociative Disorders
• Sexual and Gender Identity Disorders
• Eating Disorders
• Sleep Disorders
• Impulse-Control Disorders Not Elsewhere Classified
• Adjustment Disorders
• Personality Disorders
• “Other Conditions That May Be a Focus of Clinical Attention”
• Psychological Factors Affecting Medical Condition
• Medication-Induced Movement Disorders
• Other Medication-Induced Disorder
• Relational Problems
• Problems Related to Abuse or Neglect
• Additional Conditions: Noncompliance with treatment; malingering; bereavement; academic problem; occupational problem; others

• Correct factual errors
• Update information
• Add information from literature reviews
• Enhance educational value
• Update ICD-9-CM codes
• No substantive changes in criteria sets

• Diagnostic Criteria, including illustrative examples
• Subtypes and/or Specifiers
• Recording Procedures (ICD-9-CM Codes)
• Associated Features and Disorders
• Descriptive clinical features, laboratory findings, physical examination findings, associated general medical conditions
• Specific Culture, Age, and Gender Features
• Prevalence
• Course
• Familial Pattern
• Differential Diagnosis

• Anticipated Publication: 05/2013
• Examples of Proposed Diagnoses
• Temper Dysregulation Disorder with Dysphoria
• Social Communication Disorder
• Polysubstance-Use Disorder
• Mixed Anxiety Depression
• Premenstrual Dysphoric Disorder
• Skin Picking Disorder
• Hoarding Disorder
• Binge Eating Disorder
• Restless Legs Syndrome

• “No definition adequately specifies precise boundaries for the concept of ‘mental disorder…’”
• “The term ‘mental disorder’ unfortunately implies a distinction between ‘mental’ disorders and ‘physical disorders that is a reductionistic anachronism of mind/body dualism.”
• “A compelling literature documents that there is much ‘physical’ in ‘mental’ disorders and much ‘mental’ in ‘physical’ disorders.”
• “… Different situations call for different definitions.”
• “In DSM-IV, each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress or disability or with a significantly increased risk of suffering death, pain, disability, or important loss of freedom.”
• “… Not merely an expectable and culturally sanctioned response to a particular event.”

• “A common misconception is that a classification of mental disorders classifies people, when actually what are being classified are the disorders people have.”
• “…There is no assumption that each category of mental disorder is a completely discrete entity with absolute boundaries dividing it from other mental disorders or from no mental disorder.”
• …Includes polythetic criteria sets, in which the individual need only present with a subset of items from a longer list…”

• “The diagnostic categories, criteria, and textual descriptions are meant to be employed by individual with an appropriate clinical training and experience in diagnosis.”
• “The specific diagnostic criteria include in the DSM-IV are meant to serve as guidelines to be informed by clinical judgment and are not meant to be used in a cookbook fashion.”

• “The clinical diagnosis of a DSM-IV mental disorder is not sufficient to establish the existence for legal purposes of a ‘mental disorder’…”
• “In determining whether an individual meets a specified legal standard, additional information is usually required beyond that contained in the DSM-IV diagnosis.”

“… Includes three types of information specifically related to cultural considerations: 1)… cultural variations in clinical presentations…; 2) a description of culture-bound syndromes that have not bee included…; 3) an outline for cultural formulation designed to assist the clinician in systematically evaluating and reporting the impact of the individual’s cultural content.”

“Making a DSM-IV diagnosis is only the first step in a comprehensive evaluation. To formulate an adequate treatment plan, the clinician will invariably require considerable additional information about the person being evaluated beyond that required to make a DSM-IV diagnosis.”

• Official Coding System (U.S.): International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)
• Most DSM-IV disorders have a numerical ICD-9-CM Code (Published by the World Health Organization)
• On January 16, 2009 HHS published a final rule adopting ICD-10-CM (and ICD-10-PCS) to replace ICD-9-CM in HIPAA transactions, effective implementation date of October 1, 2013. Until that time the codes in ICD-10-CM are not valid for any purpose or use

• Assessment involves five axes, each of which refers to a different domain of information that may help the clinician plan treatment and predict outcome.
• Serves as a standardized format for organizing and communicating clinical information
• Promote the application of the biopsychosocial model in clinical, educational, and research settings

• Clinical Disorders
• 15 Major Diagnostic Categories
• Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence (Excluding Mental Retardation)
• Delirium, Dementia, and Amnestic and Other Cognitive Disorders
• Mental Disorders Due to a General Medical Condition
• Substance-Related Disorders
• Schizophrenia and Other Psychotic Disorders
• Mood Disorders
• Anxiety Disorders
• Somatoform Disorders
• Factitious Disorders
• Dissociative Disorders
• Sexual and Gender Identity Disorders
• Eating Disorders
• Sleep Disorders
• Impulse-Control Disorders Not Elsewhere Classified
• Adjustment Disorders
• Personality Disorders - Excluded
• Documentation: If more than 1 disorder, list principle diagnosis or reason for visit first
• Other Conditions That May Be a Focus of Clinical Attention

• Personality Disorders
• Mental Retardation
• May also be used for noting prominent maladaptive personality features and defense mechanisms
• “Separate axes ensures that consideration will be given to the possible presence… that might otherwise be overlooked when attention is directed to the usually more florid AXIS I disorders.”
• Documentation: Can be noted as the principle diagnosis or reason for visit whether or not AXIS I diagnosis is present

• For reporting current general medical conditions that are potentially relevant to the understanding or management of the individual’s mental disorder.”
• “The purpose of distinguishing general medical conditions is to encourage thoroughness in evaluation and to enhance communication among health care providers.”
• “When a mental disorder is judged to be a direct physiological consequence of the general medical condition, a Mental Disorder Due to a General Medical Condition should be diagnosed on AXIS I and the general medical condition should be recorded on both AXIS I and AXIS III.”

• “… For reporting psychological and environmental problems that may affect the diagnosis, treatment, and prognosis of mental disorders (AXIS I and II).”
• “In general… note only those psychosocial and environmental problems that have been present during the year preceding the current evaluation.”
• “… When a psychosocial or environmental problem is the primary focus of clinical attention, it should be recorded on AXIS I.”

• “… For reporting the clinician’s judgment of the individual’s overall level of functioning.”
• “This information is useful in planning treatment and measuring its impact, and in predicting outcome.”
• “The GAF is to be rated with respect only to psychological, social, and occupational functioning.”
• Do not include impairment due to physical or environmental limitations
• 10 Ranges of Functioning
• Selection of single value based on description of symptom severity OR level of functioning
• Selection should be based on current symptoms, or sometimes as lowest level of functioning for the past week

• 91 - 100 Superior functioning in a wide range of activities, life's problems never seem to get out of hand, is sought out by others because of his or her many positive qualities. No symptoms.
• 81 - 90 Absent or minimal symptoms (e.g., mild anxiety before an exam), good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns (e.g., an occasional argument with family members).
• 71 - 80 If symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork).
• 61 - 70 Some mild symptoms (e.g., depressed mood and mild insomnia) OR some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships.
• 51 - 60 Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers).
• 41 - 50 Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job).
• 31 - 40 Some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) OR major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school).
• 21 - 30 Behavior is considerably influenced by delusions or hallucinations OR serious impairment, in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) OR inability to function in almost all areas (e.g., stays in bed all day, no job, home, or friends)
• 11 - 20 Some danger of hurting self or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement) OR occasionally fails to maintain minimal personal hygiene (e.g., smears feces) OR gross impairment in communication (e.g., largely incoherent or mute).
• 1 - 10 Persistent danger of severely hurting self or others (e.g., recurrent violence) OR persistent inability to maintain minimal personal hygiene OR serious suicidal act with clear expectation of death.

• Describes observable behavior that represents the expression of a subjectively experienced feeling state (emotion).
• Common examples of affect are sadness, fear, joy, and anger.
• The normal range of expressed affect varies considerably between different cultures and even within the same culture.
• Types of affect include: euthymic, irritable, constricted; blunted; full, flat; inappropriate, and labile.

• A pervasive and sustained emotion that colors the perception of the world.
• Common examples of mood include depression, elation, anger, and anxiety.
• In contrast to affect, which refers to more fluctuating changes in emotional "weather," mood refers to a more pervasive and sustained emotional "climate."
• Types of mood include: dysphoric, depressed, anxious, elevated, euthymic, expansive, irritable.

• In psychotic mental disorders and organic brain syndromes a patient's insight into whether or not they are ill and therefore requiring treatment may be affected.
• In depression a person may lack insight into their best qualities and in mania a person may overestimate their wealth and abilities.

The process of receiving, processing, storing, and using information.

• 5 or more symptoms present during 2 week period and represent a change from previous functioning; at least one of the symptoms is either depressed mood or loss of interest or pleasure.
• Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood.
• Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)
• Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.
• Insomnia or Hypersomnia nearly every day
• Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
• Fatigue or loss of energy nearly every day
• Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
• Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
• Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
• The symptoms do not meet criteria for a Mixed Episode.
• The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).
• The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

• Depressed mood for most of the day, for more days than not, as indicated either by subjective account or observation by others, for at least 2 years. Note: In children and adolescents, mood can be irritable and duration must be at least 1 year.
• Presence, while depressed, of two (or more) of the following: poor appetite or overeating, Insomnia or Hypersomnia, low energy or fatigue, low self-esteem, poor concentration or difficulty making decisions, feelings of hopelessness
• During the 2-year period (1 year for children or adolescents) of the disturbance, the person has never been without the symptoms in Criteria A and B for more than 2 months at a time.
• No Major Depressive Episode has been present during the first 2 years of the disturbance (1 year for children and adolescents); i.e., the disturbance is not better accounted for by chronic Major Depressive Disorder, or Major Depressive Disorder, In Partial Remission.
• Note: There may have been a previous Major Depressive Episode provided there was a full remission (no significant signs or symptoms for 2 months) before development of the Dysthymic Disorder. In addition, after the initial 2 years (1 year in children or adolescents) of Dysthymic Disorder, there may be superimposed episodes of Major Depressive Disorder, in which case both diagnoses may be given when the criteria are met for a Major Depressive Episode.
• There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode, and criteria have never been met for Cyclothymic Disorder.
• The disturbance does not occur exclusively during the course of a chronic Psychotic Disorder, such as Schizophrenia or Delusional Disorder.
• The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).
• The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• Early Onset: if onset is before age 21 years
• Late Onset: if onset is age 21 years or older

• A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary).
• During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
• inflated self-esteem or grandiosity
• decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
• more talkative than usual or pressure to keep talking
• flight of ideas or subjective experience that thoughts are racing
• distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
• increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
• excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
• The symptoms do not meet criteria for a Mixed Episode.
• The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
• The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).
• Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder.

• Bipolar Disorder: Hypomania Criteria
• A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual non depressed mood.
• During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
• inflated self-esteem or grandiosity
• decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
• more talkative than usual or pressure to keep talking
• flight of ideas or subjective experience that thoughts are racing
• distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
• increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
• excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., the person engages in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
• The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic.
• The disturbance in mood and the change in functioning are observable by others.
• The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features.
• The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).
• Note: Hypomanic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar II Disorder.

• Recent episode mania
• Recent episode hypomania
• Recent episode depression
• Recent episode Mixed
• Rapid cycling

• Presence (or history) of one or more Major Depressive Episodes.
• Presence (or history) of at least one Hypomanic Episode.
• There has never been a Manic Episode or a Mixed Episode.
• The mood symptoms in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
• The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• Hypomanic: if currently (or most recently) in a Hypomanic Episode
• Depressed: if currently (or most recently) in a Major Depressive Episode
• Chronic: With Catatonic Features, With Melancholic Features, With Atypical Features, With Postpartum
• Specify: course and pattern specifiers
• Longitudinal Course Specifiers (With and Without Interepisode Recovery)
• With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes)
• With Rapid Cycling

• The essential feature of an Adjustment Disorder is a psychological response to an identifiable stressor or stressors that results in the development of clinically significant emotional or behavioral symptoms.
• The symptoms must develop within 3 months after the onset of the stressor(s) (Criterion A).
• The clinical significance of the reaction is indicated either by marked distress that is in excess of what would be expected given the nature of the stressor or by significant impairment in social or occupational (academic) functioning (Criterion B). In other words, a reaction to a stressor that might be considered normal or expectable can still qualify for a diagnosis of Adjustment Disorder if the reaction is sufficiently severe to cause significant impairment.
• This category should not be used if the disturbance meets the criteria for another specific AXIS I disorder (e.g., a specific Anxiety or Mood Disorder) or is merely an exacerbation of a preexisting AXIS I or II disorder (Criterion C).
• An Adjustment Disorder may be diagnosed in the presence of another AXIS I or AXIS II disorder if the latter does not account for the pattern of symptoms that have occurred in response to the stressor.
• The diagnosis of an Adjustment Disorder also does not apply when the symptoms represent Bereavement (Criterion D).
• By definition, an Adjustment Disorder must resolve within 6 months of the termination of the stressor (or its consequences) (Criterion E).
• However, the symptoms may persist for a prolonged period (i.e., longer than 6 months) if they occur in response to a chronic stressor (e.g., a chronic, disabling general medical condition) or to a stressor that has enduring consequences (e.g., the financial and emotional difficulties resulting from a divorce).
• The stressor may be a single event (e.g., termination of a romantic relationship), or there may be multiple stressors (e.g., marked business difficulties and marital problems).
• Stressors may be recurrent (e.g., associated with seasonal business crises) or continuous (e.g., living in a crime-ridden neighborhood).
• Stressors may affect a single individual, an entire family, or a larger group or community (e.g., as in a natural disaster).
• Some stressors may accompany specific developmental events (e.g., going to school, leaving the parental home, getting married, becoming a parent, failing to attain occupational goals, retirement).

• Pathophysiology: biological, psychological, psychosocial
• Biological: genetics, neurotransmitters, endocrine, environmental,
• Psychological: neglect, conflict, trauma, upbringing, conflict, learned coping mechanisms, abuse, military service
• Psychosocial: stressors, triggers, drugs
• Genetics: 37% heritable, role of genetics depends on character of depression (probably bigger role if depression develops early, is severe and recurs)
• Monoamine oxidase theory: insufficient NE/5-HT/Dopamine
• HPA axis theory: stress induces cortisol, stress and cortisol reduce the expression of brain-derived neurotrophic factor. BDNF important for neurogenesis (axon growth, neuron survival, synaptic plasticity). Depression associated with increased CRH and cortisol and hippocampal atrophy.
• Risk Factors: female, family hx of depression, substance use/abuse, chronic medical disease, other psychiatric disorder, unemployed, separated, divorced, widowed, low SES
• Lifetime prevalence: 16.7%
• 12-mo prevalence: 6.7%
• Female to Male: 1.2 to 1
• Age of onset: 32
• Leading cause of disability
• >10% illness-related costs worldwide
• Duration of major depressive episode: 16 weeks
• 52% receive some treatment
• 42% receive adequate treatment
• 3.5% of USA treated for depression each year
• Comorbidities, lifetime and 12 month: Anxiety (59.2 and 57.5%), Substance use (24 and 8.5%), Impulse control (30 and 16%), Any (72.1 and 64%)
• Anxiety: panic, agoraphobia, specific phobia, social phobia, GAD, PTSD, OCD, SAD
• Substance Use: alcohol abuse and dependence, drug use and dependence
• Impulse control: ODD, ADHD, IED

• Lifetime prevalence: 5-6%
• About equal males and females
• More common among young, unmarried, low SES
• Comorbid anxiety and substance abuse is common
• Commonly associated with bipolar disorder
• Increased risk for experiencing a MDE (Double Depression)

• The prevalence of Adjustment Disorder has been reported to be between 2% and 8% in community samples of children and adolescents and the elderly.
• Up to 12% in hospitalized patients referred for mental health consultation
• As high as 50% in special populations exposed to specific stressors such as following cardiac surgery
• Adjustment Disorders are associated with suicide attempts, suicide, excessive substance use, and somatic complaints.

• Pathophysiology: biological, psychological psychosocial
• Biological: Genetics, neuroendocrine, circadian rhythm, environmental exposure
• Psychological: neglect, conflict, trauma, upbringing, learned coping mechanisms, hx of abuse
• Psychosocial: stressors, triggers, drugs
• Genetics: no single gene identified, one parent with BAD (25%), two parents with Bad (50%),
• Catecholamine hypothesis: primarily explains mania, excess causes mania and depletion causes depression, NE and DA implicated, L-dopa precursor to DA often produces hypomania in bipolar patients, antipsychotic meds that block DA receptors are effective in treating mania
• Permissive hypothesis: low serotonin results in manic and depressive states due to defective dampening of other neurotransmitters (NE and DA). This is why some bipolar patients do better on SSRIs
• Neuroimaging: frontal and temporal lobes most frequently affected
• Left side lesions: depression
• Right side lesions: mania
• MRI: shows increase in white matter
• PET and SPECT: prefrontal and anterior para-limbic hypo-activity in bipolar depression
• Lifetime prevalence: 3.9%
• 12 mo prevalence: 6.6%
• Commonly confused with ADHD and Anxiety disorders
• Gap between onset and diagnosis is 10 years
• Onset: 18 for BAD I, 22 for BAD II
• High rates of jailing
• Approximately 25% attempt suicide, 11% complete suicide
• Spontaneous remission may occur
• Recurrence rate is extremely high
• Depression more burden

• Pathophysiology: biological, psychological psychosocial
• Biological: Genetics, neuroendocrine, circadian rhythm, environmental exposure
• Psychological: neglect, conflict, trauma, upbringing, learned coping mechanisms, hx of abuse
• Psychosocial: stressors, triggers, drugs
• Spontaneous remission may occur
• Recurrence rate is extremely high
• Depression more burden
• High suicide risk: 10% commit suicide

• Substance abuse: alcohol up to 70%
• ADHD: 25%
• Anxiety disorders and impulse control are the most common comorbidities. Poorer outcome and treatment results.

• Anxiety disorders: 56%, more than one anxiety disorder 32%
• Personality disorder: 20.8%
• PTSD: 38%
• OCD: 3-35%
• GAD: 30%

• Prevalence in general population: 1%
• Prevalence in psych outpatients: 3-5%
• Females > Males
• Comorbid BPD: outpatients 10%, inpatients 20%
• Risk Factors: family hx of bipolar disorder
• Genetically closer to bipolar disorder than mood disorder
• Treatment similar to bipolar disorder
• 1/3 convert to mood disorder, most often bipolar II

• Sleep disorder (either increased or decreased sleep)
• Interest deficit (anhedonia)
• Guilt (worthlessness, hopelessness, regret)
• Energy deficit
• Concentration deficit
• Appetite disorder (either decreased or increased)
• Psychomotor retardation or agitation
• Suicidality

• Depressed mood
• anhEdonia
• Psychomotor agitation/retardation
• Ruminations
• Energy decrease (fatigue)
• Sleep decrease (insomnia)
• Irritability
• Oral intake (Appetite)
• No need for life (Suicide)

• Labs: CBC, Chem-7, TSH, RPR, B12/Folate, Renal function, Liver function, UA
• Look for underlying conditions

• Post-partum blues: 80%
• Post-partum depression: 5%
• Symptoms: appear within 4 weeks
• Concern for patient and child’s safety
• Treat aggressively with antidepressants

A useful screening question for dysthymia but not yet validated is: In the past 2 years, have you felt depressed or sad most days, even if you felt okay sometimes? Yes/No.

• Grandiosity
• Irritability
• Distractibility
• Decreased sleep
• Increased energy
• No need for sleep
• Euphoria
• Speedy thoughts
• Speedy talk

• Has there ever been a period of time when you were not your usual self and . . . YES NO
• you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?
• you were so irritable that you shouted at people or started fights or arguments?
• you felt much more self-confident than usual?
• you got much less sleep than usual and found you didn’t really miss it?
• you were much more talkative or spoke much faster than usual?
• thoughts raced through your head or you couldn’t slow your mind down?
• you were so easily distracted by things around you that you had trouble concentrating or staying on track?
• you had much more energy than usual?
• you were much more active or did many more things than usual?
• you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?
• you were much more interested in sex than usual?
• you did things that were unusual for you or that other people might have thought were excessive, foolish or risky?
• spending money got you or your family into trouble?

• Treat for 1 year, 2-3 years if there is a comorbid condition
• Spontaneous remission likely for single MDE
• Average duration 16 weeks
• Most will clear in 6 months
• High recurrence rate, 5-7 lifetime episodes
• Each recurrence increases probability for future recurrence by 16%
• 20% develop chronic depression
• Increased length of remission decreases risk for recurrence
• Conversion to BAD I: 8%
• Conversion to BAD II: 12%
• Suicide risk: 10-15%

• Psychotherapy is effective
• Pharmacotherapy sometimes needed

• Therapeutic alliance
• Psychoeducation
• Lifestyle management
• Psychotherapy and pharmacotherapy
• First line: lithium, valproic acid, Tegretol
• Most atypical antipsychotics are efficacious

• Sex
• Age
• Depression (especially with global insomnia, severe anhedonia, severe anxiety, agitation, and panic
• attacks)
• Previous attempt
• recent Ethanol abuse
• Rational thought loss
• Social supports lacking
• Organized plan
• No spouse
• Sickness

Diagnoses (especially major depression, bipolar illness and/or psychosis), available means/weapons, recent life-altering events (death, divorce, etc.), command hallucinations, religious preoccupation, persistent hostile environment, frightened friends and relative.

• Never accept the first “No.” The first attempt is the last for the bulk of all inpatient suicides. Be non-judgmental, calm and matter-of-fact. Validate the patient’s right to view suicide as a rational solution. Understand the detailed, step-by-step evolution of thought and
• Empathize: Explicit questions about suicide intent are best explored after the person’s situation is understood and validated (e.g., “When people are very upset….”). Suicidal behavior may be understood as a communication or solution. Over the course of understanding, cognitive behavioral techniques may transform the suicide crisis and develop problem-solving skills and alternative solutions. Look for self-denigration, overgeneralization, catastrophic and/or black-or-white thinking, and other cognitive distortions.

• (Normalize): When someone feels very upset, they may have thoughts that life just isn’t worth living. Have you had such…?
• (Challenge): Your “No” does not convince me. Why wouldn’t you want to kill yourself with all that’s happened?
• (Chronologize): Walk me through every step of the last two days. A “verbal videotape”….
• (Overestimate): In the last two weeks, how many times did you think of killing yourself? Twenty or thirty times?
• (Prohibit): What’s going to prevent you from killing yourself? Persuade me that….
• (Homicide/Suicide): The medical textbooks tell us that someone in your situation may have strong or just fleeting thoughts about killing _____ and then killing themselves. When have you had such thoughts?
• (Delve): You didn’t die. Was death your intention? Share what you have been thinking. What more…?
• (Eulogize): If you were to die, what would your funeral be like? What meaning does your death have?
• (Corroboration): The standard of care requires contact with corroborative source(s)—if necessary, without permission.

• (Inconsistency): Do the risk factors and the reported ideation match? Is this person hiding information?
• (Impulsiveness): Was there rehearsal and planning or sudden action? A note?
• (Severity): What was the most serious past suicide attempt? What is the lethality of the actual or proposed method?
• (Archives): What experience does this institution have with this person?
• (Precipitants): Are the suicide motivators understood and what is their strength? Public humiliation (especially adolescents)? Insight? Is there a habit of manipulation?
• (Change): As a result of this suicide attempt, what, if any, major changes have occurred in the environment from whence this person came? (Intoxication): Was this person intoxicated at the time of the attempt?
• (Weapons): Are weapons available? If so, have they been removed?
• (Compassion Fatigue): Are clinicians too complacent, exhausted or angry to be effective?

• (Alliance): What is the strength of the therapeutic alliance? Is this person a partner in care planning?
• (Consultation): Is there sufficient uncertainty to seek consultation about the standard of care?
• (Denial): What other ways have you thought of killing yourself? Why not try...?
• (Persuasiveness): How persuasive and believable is this person?
• (Safety): What will this person do when suicidal thoughts return? Is there a hand-written safety plan? What are this person’s future plans?
• (Skills): What is this person’s reaction to counseling? Has this person learned and practiced new skills and strategies for resolving intense affect, rage,…? How motivated for change is this person? Insight?
• (Companion): Will someone leave with and stay with and be involved with this person? Support system?
• (Guilt): Does this person understand a suicide’s consequences for his/ her children, parents, friends,…?
• (Sobriety): What are the predicted consequences of further alcohol and/ or drug use?
• The Discharge: This person must leave in the company of a spouse, relative, close friend…someone. Prior to discharge there is a meeting between the person and involved others. During the meeting there is an explicit discussion about the level of comfort in sharing and asking about suicidal issues. There is agreement on post-discharge plans and the availability of lethal weapons.

nervousness, inside the body

fear, outside the body

• The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s).
• These symptoms or behaviors are clinically significant as evidenced by either marked distress that is in excess of what would be expected from exposure to the stressor or significant impairment in social or occupational (academic) functioning.
• The stress-related disturbance does not meet the criteria for another specific AXIS I disorder and is not merely an exacerbation of a preexisting AXIS I or AXIS II disorder.
• The symptoms do not represent Bereavement.
• Once the stressor (or its consequences) has terminated, the symptoms do not persist for more than an additional 6 months.
• With Anxiety. This subtype should be used when the predominant manifestations are symptoms such as nervousness, worry, or jitteriness, or, in children, fears of separation from major attachment figures.

• The essential feature of Generalized Anxiety Disorder is excessive anxiety and worry (apprehensive expectation), occurring more days than not for a period of at least 6 months, about a number of events or activities (Criterion A).
• The individual finds it difficult to control the worry (Criterion B).
• The anxiety and worry are accompanied by at least three additional symptoms from a list that includes restlessness, being easily fatigued, difficulty concentrating, irritability, muscle tension, and disturbed sleep (only one additional symptom is required in children) (Criterion C).
• The focus of the anxiety and worry is not confined to features of another AXIS I disorder such as having a Panic Attack (as in Panic Disorder), being embarrassed in public (as in Social Phobia), being contaminated (as in Obsessive-Compulsive Disorder), being away from home or close relatives (as in Separation Anxiety Disorder), gaining weight (as in Anorexia Nervosa), having multiple physical complaints (as in Somatization Disorder), or having a serious illness (as in Hypochondriasis), and the anxiety and worry do not occur exclusively during Posttraumatic Stress Disorder (Criterion D).
• Although individuals with Generalized Anxiety Disorder may not always identify the worries as "excessive," they report subjective distress due to constant worry, have difficulty controlling the worry, or experience related impairment in social, occupational, or other important areas of functioning (Criterion E).
• The disturbance is not due to the direct physiological effects of a substance (i.e., a drug of abuse, a medication, or toxin exposure) or a general medical condition and does not occur exclusively during a Mood Disorder, a Psychotic Disorder, or a Pervasive Developmental Disorder (Criterion F).
• The intensity, duration, or frequency of the anxiety and worry is far out of proportion to the actual likelihood or impact of the feared event.
• The person finds it difficult to keep worrisome thoughts from interfering with attention to tasks at hand and has difficulty stopping the worry.
• Adults with Generalized Anxiety Disorder often worry about everyday, routine life circumstances such as possible job responsibilities, finances, the health of family members, misfortune to their children, or minor matters (such as household chores, car repairs, or being late for appointments).
• Children with Generalized Anxiety Disorder tend to worry excessively about their competence or the quality of their performance.
• During the course of the disorder, the focus of worry may shift from one concern to another.

• A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes:
• palpitations, pounding heart, or accelerated heart rate
• sweating
• trembling or shaking
• sensations of shortness of breath or smothering
• feeling of choking
• chest pain or discomfort
• nausea or abdominal distress
• feeling dizzy, unsteady, lightheaded, or faint
• derealization (feelings of unreality) or depersonalization (being detached from oneself)
• fear of losing control or going crazy
• fear of dying
• paresthesias (numbness or tingling sensations)
• chills or hot flushes

• The essential feature of Panic Disorder is the presence of recurrent, unexpected Panic Attacks followed by at least 1 month of persistent concern about having another Panic Attack, worry about the possible implications or consequences of the Panic Attacks, or a significant behavioral change related to the attacks (Criterion A).
• The Panic Attacks are not due to the direct physiological effects of a substance (e.g., Caffeine Intoxication) or a general medical condition (e.g., hyperthyroidism) (Criterion C). Finally, the Panic Attacks are not better accounted for by another mental disorder (e.g., Specific or Social Phobia, Obsessive-Compulsive Disorder, Posttraumatic Stress Disorder, or Separation Anxiety Disorder) (Criterion D). Depending on whether criteria are also met for Agoraphobia (see Criteria for Agoraphobia), 300.21 Panic Disorder With Agoraphobia or 300.01Panic Disorder Without Agoraphobia is diagnosed (Criterion B).
• An unexpected (spontaneous, uncued) Panic Attack is defined as one that an individual does not immediately associate with a situational trigger (i.e., it is perceived as occurring "out of the blue").
• Situational triggers can include stimuli that are either external (e.g., a phobic object or situation) or internal (e.g., physiological arousal) to the individual. In some instances, although a situational trigger may be apparent to the clinician, it may not be readily identifiable to the individual experiencing the Panic Attack. For example, an individual may not immediately identify increased autonomic arousal induced by a hot, stuffy room, or feelings of faintness produced by quickly sitting up as triggers for a Panic Attack, and as such, these attacks are considered at the time to be unexpected.
• At least two unexpected Panic Attacks are required for the diagnosis, but most individuals have considerably more.
• Individuals with Panic Disorder frequently also have situationally predisposed Panic Attacks (i.e., those more likely to occur on, but not invariably associated with, exposure to a situational trigger).
• Situationally bound attacks (i.e., those that occur almost invariably and immediately on exposure to a situational trigger) can occur but are less common.
• The frequency and severity of the Panic Attacks vary widely. For example, some individuals have moderately frequent attacks (e.g., once a week) that occur regularly for months at a time. Others report short bursts of more frequent attacks (e.g., daily for a week) separated by weeks or months without any attacks or with less frequent attacks (e.g., two each month) over many years.
• Limited-symptom attacks (i.e., attacks that are identical to "full" Panic Attacks except that the sudden fear or anxiety is accompanied by fewer than 4 of the 13 symptoms) are very common in individuals with Panic Disorder.
• Although the distinction between full Panic Attacks and limited-symptom attacks is somewhat arbitrary, full Panic Attacks are typically associated with greater morbidity (e.g., greater health care utilization, greater functional impairment, poorer quality of life).
• Individuals with Panic Disorder display characteristic concerns or attributions about the implications or consequences of the Panic Attacks. Some fear that the attacks indicate the presence of an undiagnosed, life-threatening illness (e.g., cardiac disease, seizure disorder). Despite repeated medical testing and reassurance, they may remain frightened and unconvinced that they do not have a life-threatening illness. Others fear that the Panic Attacks are an indication that they are "going crazy" or losing control or are emotionally weak.
• Some individuals with recurrent Panic Attacks significantly change their behavior (e.g., quit a job, avoid physical exertion) in response to the attacks, but deny either fear of having another attack or concerns about the consequences of their Panic Attacks.
• Concerns about the next attack, or its implications, are often associated with development of avoidant behavior that may meet criteria for Agoraphobia, in which case Panic Disorder With Agoraphobia is diagnosed.

• Recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress
• The thoughts, impulses, or images are not simply excessive worries about real-life problems
• The person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action
• The person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion)

• Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly
• The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive
• At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable. Note: this does not apply to children.
• The obsessions or compulsions cause marked distress, are time consuming (take more than 1 hour a day), or significantly interfere with the person's normal routine, occupational (or academic) functioning, or usual social activities or relationships.
• If another AXIS I disorder is present, the content of the obsessions or compulsions is not restricted to it (e.g., preoccupation with food in the presence of an eating disorder; hair pulling in the presence of trichotillomania; concern with appearance in the presence of body dysmorphic disorder; preoccupation with drugs in the presence of a substance use disorder; preoccupation with having a serious illness in the presence of hypochondriasis; preoccupation with sexual urges or fantasies in the presence of a paraphilia; or guilty ruminations in the presence of major depressive disorder).
• The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

• The essential features of Obsessive-Compulsive Disorder are recurrent obsessions or compulsions (Criterion A) that are severe enough to be time consuming (i.e., they take more than 1 hour a day) or cause marked distress or significant impairment (Criterion C). At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable (Criterion B). If another AXIS I disorder is present, the content of the obsessions or compulsions is not restricted to it (Criterion D). The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (Criterion E).
• Obsessions are persistent ideas, thoughts, impulses, or images that are experienced as intrusive and inappropriate and that cause marked anxiety or distress. The intrusive and inappropriate quality of the obsessions has been referred to as "ego-dystonic." This refers to the individual's sense that the content of the obsession is alien, not within his or her own control, and not the kind of thought that he or she would expect to have. However, the individual is able to recognize that the obsessions are the product of his or her own mind and are not imposed from without (as in thought insertion).
• The most common obsessions are repeated thoughts about contamination (e.g., becoming contaminated by shaking hands), repeated doubts (e.g., wondering whether one has performed some act such as having hurt someone in a traffic accident or having left a door unlocked), a need to have things in a particular order (e.g., intense distress when objects are disordered or asymmetrical), aggressive or horrific impulses (e.g., to hurt one's child or to shout an obscenity in church), and sexual imagery (e.g., a recurrent pornographic image). The thoughts, impulses, or images are not simply excessive worries about real-life problems (e.g., concerns about current ongoing difficulties in life, such as financial, work, or school problems) and are unlikely to be related to a real-life problem.
• The individual with obsessions usually attempts to ignore or suppress such thoughts or impulses or to neutralize them with some other thought or action (i.e., a compulsion). For example, an individual plagued by doubts about having turned off the stove attempts to neutralize them by repeatedly checking to ensure that it is off.
• Compulsions are repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) the goal of which is to prevent or reduce anxiety or distress, not to provide pleasure or gratification. In most cases, the person feels driven to perform the compulsion to reduce the distress that accompanies an obsession or to prevent some dreaded event or situation. For example, individuals with obsessions about being contaminated may reduce their mental distress by washing their hands until their skin is raw; individuals distressed by obsessions about having left a door unlocked may be driven to check the lock every few minutes; individuals distressed by unwanted blasphemous thoughts may find relief in counting to 10 backward and forward 100 times for each thought. In some cases, individuals perform rigid or stereotyped acts according to idiosyncratically elaborated rules without being able to indicate why they are doing them. By definition, compulsions are either clearly excessive or are not connected in a realistic way with what they are designed to neutralize or prevent. The most common compulsions involve washing and cleaning, counting, checking, requesting or demanding assurances, repeating actions, and ordering.
• By definition, adults with Obsessive-Compulsive Disorder have at some point recognized that the obsessions or compulsions are excessive or unreasonable. This requirement does not apply to children because they may lack sufficient cognitive awareness to make this judgment. However, even in adults there is a broad range of insight into the reasonableness of the obsessions or compulsions. Some individuals are uncertain about the reasonableness of their obsessions or compulsions, and any given individual's insight may vary across times and situations. For example, the person may recognize a contamination compulsion as unreasonable when discussing it in a "safe situation" (e.g., in the therapist's office), but not when forced to handle money. At those times when the individual recognizes that the obsessions and compulsions are unreasonable, he or she may desire or attempt to resist them. When attempting to resist a compulsion, the individual may have a sense of mounting anxiety or tension that is often relieved by yielding to the compulsion. In the course of the disorder, after repeated failure to resist the obsessions or compulsions, the individual may give in to them, no longer experience a desire to resist them, and may incorporate the compulsions into his or her daily routines.
• The obsessions or compulsions must cause marked distress, be time consuming (take more than 1 hour per day), or significantly interfere with the individual's normal routine, occupational functioning, or usual social activities or relationships with others. Obsessions or compulsions can displace useful and satisfying behavior and can be highly disruptive to overall functioning. Because obsessive intrusions can be distracting, they frequently result in inefficient performance of cognitive tasks that require concentration, such as reading or computation. In addition, many individuals avoid objects or situations that provoke obsessions or compulsions. Such avoidance can become extensive and can severely restrict general functioning.

The person has been exposed to a traumatic event in which both of the following were present: the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others AND the person's response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior

• The traumatic event is persistently reexperienced in one (or more) of the following ways:
• Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: in young children, repetitive play may occur in which themes or aspects of the trauma are expressed.
• Recurrent distressing dreams of the event. Note: in children, there may be frightening dreams without recognizable content.
• Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). Note: in young children, trauma-specific reenactment may occur.
• Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
• Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

• Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:
• Efforts to avoid thoughts, feelings, or conversations associated with the trauma
• Efforts to avoid activities, places, or people that arouse recollections of the trauma
• Inability to recall an important aspect of the trauma
• Markedly diminished interest or participation in significant activities
• Feeling of detachment or estrangement from others
• Restricted range of affect (e.g., unable to have loving feelings)
• Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)

• Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:
• Difficulty falling or staying asleep
• Irritability or outbursts of anger
• Difficulty concentrating
• Hypervigilance
• Exaggerated startle response

• 1 mo
• Acute: if duration of symptoms is less than 3 months
• Chronic: if duration of symptoms is 3 months or more
• With Delayed Onset: if onset of symptoms is at least 6 months after the stressor

• The essential feature of Posttraumatic Stress Disorder is the development of characteristic symptoms following exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one's physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate (Criterion A1). The person's response to the event must involve intense fear, helplessness, or horror (or in children, the response must involve disorganized or agitated behavior) (Criterion A2). The characteristic symptoms resulting from the exposure to the extreme trauma include persistent reexperiencing of the traumatic event (Criterion B), persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (Criterion C), and persistent symptoms of increased arousal (Criterion D). The full symptom picture must be present for more than 1 month (Criterion E), and the disturbance must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion F).
• Traumatic events that are experienced directly include, but are not limited to, military combat, violent personal assault (sexual assault, physical attack, robbery, mugging), being kidnapped, being taken hostage, terrorist attack, torture, incarceration as a prisoner of war or in a concentration camp, natural or manmade disasters, severe automobile accidents, or being diagnosed with a life-threatening illness. For children, sexually traumatic events may include developmentally inappropriate sexual experiences without threatened or actual violence or injury. Witnessed events include, but are not limited to, observing the serious injury or unnatural death of another person due to violent assault, accident, war, or disaster or unexpectedly witnessing a dead body or body parts. Events experienced by others that are learned about include, but are not limited to, violent personal assault, serious accident, or serious injury experienced by a family member or a close friend; learning about the sudden, unexpected death of a family member or a close friend; or learning that one's child has a life-threatening disease. The disorder may be especially severe or long lasting when the stressor is of human design (e.g., torture, rape). The likelihood of developing this disorder may increase as the intensity of and physical proximity to the stressor increase.
• The traumatic event can be reexperienced in various ways. Commonly the person has recurrent and intrusive recollections of the event (Criterion B1) or recurrent distressing dreams during which the event can be replayed or otherwise represented (Criterion B2). In rare instances, the person experiences dissociative states that last from a few seconds to several hours, or even days, during which components of the event are relived and the person behaves as though experiencing the event at that moment (Criterion B3). These episodes, often referred to as "flashbacks," are typically brief but can be associated with prolonged distress and heightened arousal. Intense psychological distress (Criterion B4) or physiological reactivity (Criterion B5) often occurs when the person is exposed to triggering events that resemble or symbolize an aspect of the traumatic event (e.g., anniversaries of the traumatic event; cold, snowy weather or uniformed guards for survivors of death camps in cold climates; hot, humid weather for combat veterans of the South Pacific; entering any elevator for a woman who was raped in an elevator).
• Stimuli associated with the trauma are persistently avoided. The person commonly makes deliberate efforts to avoid thoughts, feelings, or conversations about the traumatic event (Criterion C1) and to avoid activities, situations, or people who arouse recollections of it (Criterion C2). This avoidance of reminders may include amnesia for an important aspect of the traumatic event (Criterion C3). Diminished responsiveness to the external world, referred to as "psychic numbing" or "emotional anesthesia," usually begins soon after the traumatic event. The individual may complain of having markedly diminished interest or participation in previously enjoyed activities (Criterion C4), of feeling detached or estranged from other people (Criterion C5), or of having markedly reduced ability to feel emotions (especially those associated with intimacy, tenderness, and sexuality) (Criterion C6). The individual may have a sense of a foreshortened future (e.g., not expecting to have a career, marriage, children, or a normal life span) (Criterion C7).
• The individual has persistent symptoms of anxiety or increased arousal that were not present before the trauma. These symptoms may include difficulty falling or staying asleep that may be due to recurrent nightmares during which the traumatic event is relived (Criterion D1), hypervigilance (Criterion D4), and exaggerated startle response (Criterion D5). Some individuals report irritability or outbursts of anger (Criterion D2) or difficulty concentrating or completing tasks (Criterion D3).

• A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing. Note: In children, there must be evidence of the capacity for age-appropriate social relationships with familiar people and the anxiety must occur in peer settings, not just in interactions with adults.
• Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally predisposed Panic Attack. Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or shrinking from social situations with unfamiliar people.
• The person recognizes that the fear is excessive or unreasonable. Note: In children, this feature may be absent.
• The feared social or performance situations are avoided or else are endured with intense anxiety or distress.
• The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person's normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.
• In individuals under age 18 years, the duration is at least 6 months.
• The fear or avoidance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition and is not better accounted for by another mental disorder (e.g., Panic Disorder With or Without Agoraphobia, Separation Anxiety Disorder, Body Dysmorphic Disorder, a Pervasive Developmental Disorder, or Schizoid Personality Disorder).
• If a general medical condition or another mental disorder is present, the fear in Criterion A is unrelated to it, e.g., the fear is not of Stuttering, trembling in Parkinson's disease, or exhibiting abnormal eating behavior in Anorexia Nervosa or Bulimia Nervosa.
• Specify if Generalized: if the fears include most social situations (also consider the additional diagnosis of Avoidant Personality Disorder)

• The essential feature of Social Phobia is a marked and persistent fear of social or performance situations in which embarrassment may occur (Criterion A). Exposure to the social or performance situation almost invariably provokes an immediate anxiety response (Criterion B). This response may take the form of a situationally bound or situationally predisposed Panic Attack (see Here). Although adolescents and adults with this disorder recognize that their fear is excessive or unreasonable (Criterion C), this may not be the case with children. Most often, the social or performance situation is avoided, although it is sometimes endured with dread (Criterion D). The diagnosis is appropriate only if the avoidance, fear, or anxious anticipation of encountering the social or performance situation interferes significantly with the person's daily routine, occupational functioning, or social life, or if the person is markedly distressed about having the phobia (Criterion E). In individuals younger than age 18 years, symptoms must have persisted for at least 6 months before Social Phobia is diagnosed (Criterion F). The fear or avoidance is not due to the direct physiological effects of a substance or a general medical condition and is not better accounted for by another mental disorder (e.g., Panic Disorder, Separation Anxiety Disorder, Body Dysmorphic Disorder, a Pervasive Developmental Disorder, or Schizoid Personality Disorder) (Criterion G). If another mental disorder or general medical condition is present (e.g., Stuttering, Parkinson's disease, Anorexia Nervosa), the fear or avoidance is not limited to concern about its social impact (Criterion H).
• In feared social or performance situations, individuals with Social Phobia experience concerns about embarrassment and are afraid that others will judge them to be anxious, weak, "crazy," or stupid. They may fear public speaking because of concern that others will notice their trembling hands or voice or they may experience extreme anxiety when conversing with others because of fear that they will appear inarticulate. They may avoid eating, drinking, or writing in public because of a fear of being embarrassed by having others see their hands shake. Individuals with Social Phobia almost always experience symptoms of anxiety (e.g., palpitations, tremors, sweating, gastrointestinal discomfort, diarrhea, muscle tension, blushing, confusion) in the feared social situations, and, in severe cases, these symptoms may meet the criteria for a Panic Attack (see Criteria for Panic Attack). Blushing may be more typical of Social Phobia.
• Adults with Social Phobia recognize that the fear is excessive or unreasonable, although this is not always the case in children. For example, the diagnosis would be Delusional Disorder instead of Social Phobia for an individual who avoids eating in public because of a conviction that he or she will be observed by the police and who does not recognize that this fear is excessive and unreasonable. Moreover, the diagnosis should not be given if the fear is reasonable given the context of the stimuli (e.g., fear of being called on in class when unprepared).
• The person with Social Phobia typically will avoid the feared situations. Less commonly, the person forces himself or herself to endure the social or performance situation, but experiences it with intense anxiety. Marked anticipatory anxiety may also occur far in advance of upcoming social or public situations (e.g., worrying every day for several weeks before attending a social event). There may be a vicious cycle of anticipatory anxiety leading to fearful cognition and anxiety symptoms in the feared situations, which leads to actual or perceived poor performance in the feared situations, which leads to embarrassment and increased anticipatory anxiety about the feared situations, and so on.
• The fear or avoidance must interfere significantly with the person's normal routine, occupational or academic functioning, or social activities or relationships, or the person must experience marked distress about having the phobia. For example, a person who is afraid of speaking in public would not receive a diagnosis of Social Phobia if this activity is not routinely encountered on the job or in the classroom and the person is not particularly distressed about it. Fears of being embarrassed in social situations are common, but usually the degree of distress or impairment is insufficient to warrant a diagnosis of Social Phobia. Transient social anxiety or avoidance is especially common in childhood and adolescence (e.g., an adolescent girl may avoid eating in front of boys for a short time, then resume usual behavior). In those younger than age 18 years, only symptoms that persist for at least 6 months qualify for the diagnosis of Social Phobia.

• Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood).
• Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, which may take the form of a situationally bound or situationally predisposed Panic Attack. Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or clinging.
• The person recognizes that the fear is excessive or unreasonable. Note: In children, this feature may be absent.
• The phobic situation(s) is avoided or else is endured with intense anxiety or distress.
• The avoidance, anxious anticipation, or distress in the feared situation(s) interferes significantly with the person's normal routine, occupational (or academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.
• In individuals under age 18 years, the duration is at least 6 months.
• The anxiety, Panic Attacks, or phobic avoidance associated with the specific object or situation are not better accounted for by another mental disorder, such as Obsessive-Compulsive Disorder (e.g., fear of dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g., avoidance of stimuli associated with a severe stressor), Separation Anxiety Disorder (e.g., avoidance of school), Social Phobia (e.g., avoidance of social situations because of fear of embarrassment), Panic Disorder With Agoraphobia, or Agoraphobia Without History of Panic Disorder.
• Specify type: Animal type, Natural environment type (heights, storms, water), Blood-injection-injury type, Situational type (airplanes, elevators, enclosed places), Other type (fear of choking, vomiting, or contracting an illness; in children, fear of loud sounds or costumed characters)

• The essential feature of Specific Phobia is marked and persistent fear of clearly discernible, circumscribed objects or situations (Criterion A). Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response (Criterion B). This response may take the form of a situationally bound or situationally predisposed Panic Attack (see Features). Although adolescents and adults with this disorder recognize that their fear is excessive or unreasonable (Criterion C), this may not be the case with children. Most often, the phobic stimulus is avoided, although it is sometimes endured with dread (Criterion D). The diagnosis is appropriate only if the avoidance, fear, or anxious anticipation of encountering the phobic stimulus interferes significantly with the person's daily routine, occupational functioning, or social life, or if the person is markedly distressed about having the phobia (Criterion E). In individuals under age 18 years, symptoms must have persisted for at least 6 months before Specific Phobia is diagnosed (Criterion F). The anxiety, Panic Attacks, or phobic avoidance are not better accounted for by another mental disorder (e.g., Obsessive-Compulsive Disorder, Posttraumatic Stress Disorder, Separation Anxiety Disorder, Social Phobia, Panic Disorder With Agoraphobia, or Agoraphobia Without History of Panic Disorder) (Criterion G).
• The individual experiences a marked, persistent, and excessive or unreasonable fear when in the presence of, or when anticipating an encounter with, a specific object or situation. The focus of the fear may be anticipated harm from some aspect of the object or situation (e.g., an individual may fear air travel because of a concern about crashing, may fear dogs because of concerns about being bitten, or may fear driving because of concerns about being hit by other vehicles on the road). Specific Phobias may also involve concerns about losing control, panicking, somatic manifestations of anxiety and fear (such as increased heart rate or shortness of breath), and fainting that might occur on exposure to the feared object. For example, individuals afraid of blood and injury may also worry about the possibility of fainting; people afraid of heights may also worry about dizziness; and people afraid of closed-in situations may also worry about losing control and screaming. These concerns may be particularly strong in the Situational Type of Specific Phobia.
• Anxiety is almost invariably felt immediately on confronting the phobic stimulus (e.g., a person with a Specific Phobia of cats will almost invariably have an immediate anxiety response when forced to confront a cat). The level of anxiety or fear usually varies as a function of both the degree of proximity to the phobic stimulus (e.g., fear intensifies as the cat approaches and decreases as the cat withdraws) and the degree to which escape from the phobic stimulus is limited (e.g., fear intensifies as the elevator approaches the midway point between floors and decreases as the doors open at the next floor). However, the intensity of the fear may not always relate predictably to the phobic stimulus (e.g., a person afraid of heights may experience variable amounts of fear when crossing the same bridge on different occasions). Sometimes full-blown Panic Attacks are experienced in response to the phobic stimulus, especially when the person must remain in the situation or believes that escape will be impossible. Occasionally, the Panic Attacks are delayed and do not occur immediately upon confronting the phobic stimulus. This delay is more likely in the Situational Type. Because marked anticipatory anxiety occurs if the person is confronted with the necessity of entering into the phobic situation, such situations are usually avoided. Less commonly, the person forces himself or herself to endure the phobic situation, but it is experienced with intense anxiety.
• Adults with this disorder recognize that the phobia is excessive or unreasonable. The diagnosis would be Delusional Disorder instead of Specific Phobia for an individual who avoids an elevator because of a conviction that it has been sabotaged and who does not recognize that this fear is excessive and unreasonable. Moreover, the diagnosis should not be given if the fear is reasonable given the context of the stimuli (e.g., fear of being shot in a hunting area or a dangerous neighborhood). Insight into the excessive or unreasonable nature of the fear tends to increase with age and is not required to make the diagnosis in children.
• Fears of circumscribed objects or situations are very common, especially in children, but in many cases the degree of impairment is insufficient to warrant a diagnosis. If the phobia does not significantly interfere with the individual's functioning or cause marked distress, the diagnosis is not made. For example, a person who is afraid of snakes to the point of expressing intense fear in the presence of snakes would not receive a diagnosis of Specific Phobia if he or she lives in an area devoid of snakes, is not restricted in activities by the fear of snakes, and is not distressed about having a fear of snakes.
• Subtypes
• The following subtypes may be specified to indicate the focus of fear or avoidance in Specific Phobia (e.g., Specific Phobia, Animal Type).
• Animal Type. This subtype should be specified if the fear is cued by animals or insects. This subtype generally has a childhood onset.
• Natural Environment Type. This subtype should be specified if the fear is cued by objects in the natural environment, such as storms, heights, or water. This subtype generally has a childhood onset.
• Blood-Injection-Injury Type. This subtype should be specified if the fear is cued by seeing blood or an injury or by receiving an injection or other invasive medical procedure. This subtype is highly familial and is often characterized by a strong vasovagal response.
• Situational Type. This subtype should be specified if the fear is cued by a specific situation such as public transportation, tunnels, bridges, elevators, flying, driving, or enclosed places. This subtype has a bimodal age-at-onset distribution, with one peak in childhood and another peak in the mid-20s. This subtype appears to be similar to Panic Disorder With Agoraphobia in its characteristic sex ratios, familial aggregation pattern, and age at onset.
• Other Type. This subtype should be specified if the fear is cued by other stimuli. These stimuli might include the fear of choking, vomiting, or contracting an illness; "space" phobia (i.e., the individual is afraid of falling down if away from walls or other means of physical support); and children's fears of loud sounds or costumed characters.
• The frequency of the subtypes in adult clinical settings, from most to least frequent, is Situational; Natural Environment; Blood-Injection-Injury; and Animal. Studies of community samples show a slightly different pattern, with phobias of heights and of spiders, mice, and insects most common, and phobias of other animals and other elements of the natural environment, such as storms, thunder, and lightning, least common. Phobias of closed-in situations (a Situational Type of phobia) may be more common in the elderly. In many cases, more than one subtype of Specific Phobia is present. Having one phobia of a specific subtype tends to increase the likelihood of having another phobia from within the same subtype (e.g., fear of cats and snakes). When more than one subtype applies, they should all be noted (e.g., Specific Phobia, Animal and Natural Environment Types).

• The person has been exposed to a traumatic event in which both of the following were present: the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others AND the person's response involved intense fear, helplessness, or horror.
• Either while experiencing or after experiencing the distressing event, the individual has three (or more) of the following dissociative symptoms: a subjective sense of numbing, detachment, or absence of emotional responsiveness, a reduction in awareness of his or her surroundings (e.g., "being in a daze"), derealization, depersonalization, dissociative amnesia (i.e., inability to recall an important aspect of the trauma).
• The traumatic event is persistently reexperienced in at least one of the following ways: recurrent images, thoughts, dreams, illusions, flashback episodes, or a sense of reliving the experience; or distress on exposure to reminders of the traumatic event.
• Marked avoidance of stimuli that arouse recollections of the trauma (e.g., thoughts, feelings, conversations, activities, places, people).
• Marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle response, motor restlessness).
• The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or impairs the individual's ability to pursue some necessary task, such as obtaining necessary assistance or mobilizing personal resources by telling family members about the traumatic experience.
• The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks and occurs within 4 weeks of the traumatic event.
• The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition, is not better accounted for by Brief Psychotic Disorder, and is not merely an exacerbation of a preexisting AXIS I or AXIS II disorder.

• The essential feature of Acute Stress Disorder is the development of characteristic anxiety, dissociative, and other symptoms that occurs within 1 month after exposure to an extreme traumatic stressor (Criterion A). For a discussion of the types of stressors involved, see the description of Posttraumatic Stress Disorder (Diagnostic Features). Either while experiencing the traumatic event or after the event, the individual has at least three of the following dissociative symptoms: a subjective sense of numbing, detachment, or absence of emotional responsiveness; a reduction in awareness of his or her surroundings; derealization; depersonalization; or dissociative amnesia (Criterion B). Following the trauma, the traumatic event is persistently reexperienced (Criterion C), and the individual displays marked avoidance of stimuli that may arouse recollections of the trauma (Criterion D) and has marked symptoms of anxiety or increased arousal (Criterion E). The symptoms must cause clinically significant distress, significantly interfere with normal functioning, or impair the individual's ability to pursue necessary tasks (Criterion F). The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks after the traumatic event (Criterion G); if symptoms persist beyond 4 weeks, the diagnosis of Posttraumatic Stress Disorder may be applied. The symptoms are not due to the direct physiological effects of a substance (i.e., a drug of abuse, a medication) or a general medical condition, are not better accounted for by Brief Psychotic Disorder, and are not merely an exacerbation of a preexisting mental disorder (Criterion H).
• As a response to the traumatic event, the individual develops dissociative symptoms. Individuals with Acute Stress Disorder may have a decrease in emotional responsiveness, often finding it difficult or impossible to experience pleasure in previously enjoyable activities, and frequently feel guilty about pursuing usual life tasks. They may experience difficulty concentrating, feel detached from their bodies, experience the world as unreal or dreamlike, or have increasing difficulty recalling specific details of the traumatic event (dissociative amnesia). In addition, at least one symptom from each of the symptom clusters required for Posttraumatic Stress Disorder is present. First, the traumatic event is persistently reexperienced (e.g., recurrent recollections, images, thoughts, dreams, illusions, flashback episodes, a sense of reliving the event, or distress on exposure to reminders of the event). Second, reminders of the trauma (e.g., places, people, activities) are avoided. Finally, hyperarousal in response to stimuli reminiscent of the trauma is present (e.g., difficulty sleeping, irritability, poor concentration, hypervigilance, an exaggerated startle response, and motor restlessness).

• The essential feature of Impulse-Control Disorders is the failure to resist an impulse, drive, or temptation to perform an act that is harmful to the person or to others. For most of the disorders in this section, the individual feels an increasing sense of tension or arousal before committing the act and then experiences pleasure, gratification, or relief at the time of committing the act. Following the act there may or may not be regret, self-reproach, or guilt. The following disorders are included in this section:
• Intermittent Explosive Disorder is characterized by discrete episodes of failure to resist aggressive impulses resulting in serious assaults or destruction of property.
• Kleptomania is characterized by the recurrent failure to resist impulses to steal objects not needed for personal use or monetary value.
• Pyromania is characterized by a pattern of fire setting for pleasure, gratification, or relief of tension.
• Pathological Gambling is characterized by recurrent and persistent maladaptive gambling behavior.
• Trichotillomania is characterized by recurrent pulling out of one's hair for pleasure, gratification, or relief of tension that results in noticeable hair loss.
• Impulse-Control Disorder Not Otherwise Specified is included for coding disorders of impulse control that do not meet the criteria for any of the specific Impulse-Control Disorders described above or in other sections of the manual.

• External or internal clue
• Amygdala stimulated
• Cascade of events stimulate Adrenal gland
• Release of cortisol/norepinephrine

• Lifetime prevalence 1-3% of the general population.
• Females > Males
• 17-25% ED pts with chest pain met criteria for panic disorder
• Often occurs in patients with Agoraphobia (26%), Social anxiety (33%)—fear of situations that may involve scrutiny or judgment by others
• One in three is depressed, one in five attempts suicide

• Bronchial Asthma
• Hypertension
• Mitral Vale Prolapse (MVP)
• Irritable Bowel Syndrome (IBS)
• Interstitial Cystitis
• Migraine Headaches

• P: Panic attacks & Paranoia
• T: Trauma (Physical, Emotional , Sexual)
• S: Symptoms : Flashbacks (re-expereincing), Nightmares
• D: Dissociation/Numbing

• D: Detachment/Dissociation
• R: Reliving/Re-experiencing the trauma (Nightmares, flashbacks and/or recollections
• E: Event (Trauma) had emotional effects (Feelings of helplessness or disabling fear)
• A: Avoidance
• M: Months in duration (More than a month)
• S: Sympathetic hyperactivity or hyper-vigilance, Insomnia, irritability, and/or difficulty concentrating

• Lifetime: 6.8% - 12.3%
• 1 year prevalence: 3.5% - 6%
• Males> Females
• Do not under-estimate in children

• Perception/initial severity of reaction to trauma
• Parental neglect
• Poor social support/Low SES
• Personal and/or family hx of psychiatric disorder

• 0.2% of postpartum women
• 18% of firefighters
• 34% in adolescent survivors of MVAs
• 48% in female rape victims
• 67% in POWs

• Foa’s brief prevention program
• Immediate on-site counseling
• Debriefing on the stress of the critical incident
• Intervention within 14 days of trauma
• Victims are educated about common responses to assault and taught breathing and muscle relaxation techniques

• Similar to PTSD: occurs just after exposure to a traumatic event
• Appears within 4 weeks of trauma, disappears within 4-weeks
• Fewer symptoms required to make diagnosis
• More dissociative symptoms (“in a daze,” temporary amnesia)
• Can progress to PTSD if untreated, more responsive to treatment than PTSD

• Direct questioning is necessary
• Trauma history (Physical, Emotional, Sexual abuse) in all Psychological assessments
• Have you served in Military? Combat?
• “Have you ever been physically/sexually attacked or assaulted?”
• Have you ever been in a severe accident?

• Having PTSD increases risk for developing other psychological disorder
• Up to 80% patients with PTSD also have a comorbid MDD and ETOH
• ALWAYS Screen for AXIS II (character) disorder
• Must treat comorbid disorders simultaneously

• Social Situations: Public speaking, Talking with authority figures, Going out to date, Strangers
• Anxiety: Panic or Panic-like symptoms (May be initial presentation)
• Distress: Poor performance &/Or Avoidance

• Two Types: Generalized, Non-generalized (Public speaking)
• An intense, irrational and persistent fear of being scrutinized or negatively evaluated by others
• History of shyness
• Panic attacks or panic like syx in context of social situations
• Choose or change jobs/career because of the nature of the disease

• Lifetime Prevalence: 3-13%
• Slightly females > males
• Onset between ages 11 and 19, after age 25 is rare
• Sometimes will be dormant/unprovoked until major life change (new job, new school)
• 85% have academic and occupational difficulties

• 50% have some other psychological disorder/s
• Other phobias, anxiety disorders
• Major Depressive Disorder x4
• Substance Abuse (Both ETOH and illicit drugs)
• Bulimia Nervosa

• GAD Risk Factors
• Middle age
• Female gender
• Separated/divorced/ widowed
• Low Socio-economic
• Family hx of GAD

• Lifetime prevalence of GAD is 4.1 to 6.6%. Highest prevalence of all anxiety disorders
• More prevalent in women than men, > 2/3 of patients with GAD are woman
• Median age of onset during early 20s
• Onset usually gradual, but can be precipitated by stressful life events, waxes and wanes

• Major depression, 35-50% meet GAD criteria
• Panic disorder (1/4 pts with GAD)
• SAD/PTSD
• Specific phobia
• Substance abuse

• Fear that is caused by a specific object or situation
• Fear may be caused by the actual presence of, or by the anticipation of the presence of, an object or situation
• Anxiety response may be a panic attack or symptoms of anxiety that do not meet criteria for a panic attack
• Patient avoids stimulus, or endures it with significant anxiety or distress
• If patient is under 18 years of age, must have had the symptoms at least 6 months
• Claustrophobia: fear of confined spaces
• Arachnophobia: fear of spiders
• Aviatophobia: fear of flying
• Dentophobia: fear of dentists
• Iatrophobia: fear of going to the doctor or of doctors
• Odynophobia: fear of pain
• Trypanophobia: fear of injections

• A reaction to stress
• Maladaptive behavior is called adjustment disorder
• Causes of stress are different at different ages
• Reactions include anxiety and depression, avoidant behavior
• Does not meet criteria for other “major” types of anxiety disorders

• Obsessions : Thoughts
• Compulsions : Behaviors
• Recurrent, Repetitive
• Excessive, irrational
• Distressing, Disturbing
• Feelings of shame and secrecy

• Contamination
• Need for order
• Repeated doubts
• Religious
• Sexual imagery
• Aggressive impulses

• Cleaning
• Ordering/organize
• Checking/Counting
• Repetitive actions
• Masturbation
• Fights

• Lifetime prevalence in GP is 2-3% (psych pt close to 10%)
• Female ~ Males
• Whites > African-americans
• Symptoms begin usually in adolescence
• More than 50% have symptom onset before their mid-20
• Average time to treatment after meeting criteria for diagnosis is 11 years

• Genetics have a strong role, especially if early onset
• Dorsolateral prefrontal cortex, basal ganglia, and thalamus
• Serotonin system is heavily involved
• Question of immunologic association
• OCD in pediatric population--autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDAS)
• Linked to group A Streptococcus

• Very difficult to detect without high awareness and suspicion
• Look for clues
• Avoid shaking hand/super-clean
• Very careful when sitting in the chair
• Chapped hands (excessive hand-washing)

• “Do you have thoughts or images that keep coming back to you and are difficult to put out of your head? For example, being contaminated by something, having something terrible happen to you or someone you care about, or doing something terrible?”
• “Do you ever feel the need to perform certain actions that don’t make sense or that you don’t want to do, such as washing, cleaning, counting, or checking things over and over?”

• Therapeutic alliance (Support, Sympathize, Empathize)
• Psycho-education (disorder/s, Dynamic)
• Rule out/in Psychological/medical diagnoses
• Physical examination
• Basic blood work
• Psychotherapy
• Pharmacotherapy
• Combined therapies
• Benefits/Risks of the treatment
• Supportive Psychotherapy: Less effective than CBT in reducing specific syx of the disorder. Helpful in addressing other significant personal issues
• Cognitive Behavioral Therapy (CBT): Combination of behavioral interventions ex. Anxiety management, relaxation, and cognitive restructuring.
• Interpersonal Therapy: Relationships
• Psychodynamic therapy: Conflicts, deficits, traumas
• Family/Marital counseling: Appropriate in some cases to address stressors

• Rapid symptomatic relief from acute anxiety states
• Restrict for severe, disabling, or subjecting the pt to extreme emotional distress
• Benzo’s at minimum effective dose , shortest period, PRN (ideally same benzo)
• Must 1st check h/o drug abuse

• SSRIs: Paxil(20-60mg/day), Zoloft (50mg-200mg) Luvox (OCD, SAD), Celexa (20-40mg) Escitalopram (10-20mg/day)
• SNRIs: Effexor XR (75-225mg/day), Cymbalta (60-120mg/d), Pretiq (50-100mg), Remeron
• DNRI: (Do not use!) Wellbutrin IR, SR, XR (100-450mg)
• TCAs: Imipramine, Doxepin, Amitriptyline. Use @ low doses 25-100 mg @ bedtime. Many less favorable adverse effects and overdose potential

• Buspar (10-40mg/day): Effective in mild sx of GAD, no antidepressant effect. slow acting. Response within 2 weeks. Low abuse/dependence than benzos
• Beta-blockers: Inderol (10-40mg). Efficacy mainly in Non-generalized SAD (public speaking. Tx of somatic sx – ex. Autonomic syx

enduring pattern of inner experience and behavior

• • Enduring pattern of inner experience and behavior deviating markedly from the expectations of the culture of the individual who exhibits the behavior
• • Personality disorders are a severe disturbance in the behavioral tendencies of an individual.
• • Usually involves several areas of the personality.
• • Nearly always associated with considerable personal and social disruption
• • Are inflexible and pervasive across many situations
• • Is ego-syntonic and perceived to be appropriate by that individual.
• • Behavior can result in adaptation of maladaptive coping skills, which may lead to personal problems such as depression, anxiety, or other types of distress.

• Paranoid
• Schizoid
• Schizotypal

• Antisocial
• Borderline
• Histrionic
• Narcissistic

• Avoidant
• Dependent
• Obsessive-compulsive
• Personality Disorder NOS

• Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her
• Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates
• Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her
• Reads hidden demeaning or threatening meanings into benign remarks or events
• Persistently bears grudges, i.e., is unforgiving of insults, injuries, or slights
• Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack
• Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner

• They do not desire or enjoy close relationships, even with family members.
• They choose solitary jobs and activities.
• They take pleasure in few activities, including sex.
• They have no close friends, except first-degree relatives.
• They have difficulty relating to others.
• They are indifferent to praise or criticism.
• They are aloof and show little emotion.
• They might daydream and/or create vivid fantasies of complex inner lives.

• Ideas of reference (excluding delusions of reference)
• Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or "sixth sense"; in children and adolescents, bizarre fantasies or preoccupations)
• Unusual perceptual experiences, including bodily illusions
• Odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped)
• Suspiciousness or paranoid ideation
• Inappropriate or constricted affect
• Behavior or appearance that is odd, eccentric, or peculiar
• Lack of close friends or confidants other than first-degree relatives
• Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self.

• Failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest
• Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure
• Impulsivity or failure to plan ahead
• Irritability and aggressiveness, as indicated by repeated physical fights or assaults
• Reckless disregard for safety of self or others
• Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations
• Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another

• Overvalue of others
• Difficulty interpreting others’ vision
• Impulsive behavior: promiscuity, improper relationships
• Underlying fear of abandonment or rejection
• Frantic efforts to avoid real or imagined abandonment
• A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
• Identity disturbance, such as a significant and persistent unstable self-image or sense of self
• Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating)
• Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
• Emotional instability due to significant reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)
• Chronic feelings of emptiness
• Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)
• Transient, stress-related paranoid thoughts or severe dissociative symptoms.

• Exaggerated self-importance
• Need for positive attention
• Need for prestige
• Grandiosity, envy, lack of empathy
• Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements)
• Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love
• Believes that he or she is "special" and unique and can only be understood by, or should associate with, other special or high-status people (or institutions)
• Requires excessive admiration
• Has a very strong sense of entitlement, e.g., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations
• Is exploitative of others, e.g., takes advantage of others to achieve his or her own ends
• Lacks empathy, e.g., is unwilling to recognize or identify with the feelings and needs of others
• Is often envious of others or believes that others are envious of him or her
• Regularly shows arrogant, haughty behaviors or attitudes

• Extensive emotionality
• Pattern of attention seeking
• Manipulative
• Needy and dependent
• Play hunches- can be bored easily and grow tired of people
• Is uncomfortable in situations in which he or she is not the center of attention
• Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior
• Displays rapidly shifting and shallow expression of emotions
• Consistently uses physical appearance to draw attention to themself
• Has a style of speech that is excessively impressionistic and lacking in detail
• Shows self-dramatization, theatricality, and exaggerated expression of emotion
• Is highly suggestible, i.e., easily influenced by others or circumstances
• Considers relationships to be more intimate than they actually are.

• Avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection
• Is unwilling to get involved with people unless certain of being liked
• Shows restraint within intimate relationships because of the fear of being shamed or ridiculed
• Is preoccupied with being criticized or rejected in social situations
• Is inhibited in new interpersonal situations because of feelings of inadequacy
• Views themself as socially inept, personally unappealing, or inferior to others
• Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing

• Social inhibition
• Specific dependee
• No confidence in themselves but always pressed to keep the dependee happy
• Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others
• Needs others to assume responsibility for most major areasof his or her life
• Has difficulty expressing disagreement with others because of fear of loss of support or approval
• Has difficulty initiating projects or doing things on his or her own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy)
• Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant
• Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself
• Urgently seeks another relationship as a source of care and support when a close relationship ends
• Is unrealistically preoccupied with fears of being left to take care of himself or herself

• Extreme orderliness
• Ritualistic
• Perfectionism
• Controlling
• The need for making lists, adhering to rules, and orderliness will override flexibility of alternate plans. ‘anal character’
• Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost
• Shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met)
• Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity)
• Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification)
• Is unable to discard worn-out or worthless objects even when they have no sentimental value
• Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things
• Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes
• Shows significant rigidity and stubbornness

• CC: Difficulty initiating sleep, Difficulty maintaining sleep, Waking up too early, or Sleep that is chronically nonrestorative or poor in quality
• Sleep difficulty occurs despite adequate opportunity and circumstances for sleep
• At least one form of daytime impairment related to nighttime sleep difficulty
• Inadequate ability to sleep
• Adequate opportunity

• Fatigue/malaise
• Attention, concentration, or memory impairment
• Social/vocational dysfunction or poor school performance
• Mood disturbance/irritability
• Daytime sleepiness
• Motivation/energy/initiative reduction
• Proneness for errors/accident at work or while driving
• Tension headaches, and/or GI symptoms in response to sleep loss
• Concerns or worries about sleep

Insomnia diagnosis assumes adequate opportunity to sleep

• Adequate ability to sleep
• Inadequate opportunity

• No polysomnographic (PSG) or quantitative criteria in diagnosis
• Diagnosis is based on self-report
• Only 50% to 60% of patients meeting insomnia criteria have significant deviations in PSG
• PSG is indicated only if Sleep apnea or periodic limb movements of sleep are suspected or diagnosis is uncertain or usual treatment fails

• 30% of the general population have disturbed sleep
• 10% of the general population meet diagnostic criteria
• 50% of patients under clinical care meet diagnostic criteria

• No DSM-IV Diagnosis (24%)
• Psychiatric Disorders (44%)
• Other Sleep Disorders (5%)
• Other Illnesses, Medications, etc (11%)
• Primary Insomnia (16%)

• Primary Insomnia increases the risk of subsequent anxiety disorder, mood disorder, substance abuse
• Is an independent risk factor for suicide in depressed
• Frequently does not resolve with treatment of associated conditions.
• Is the most frequent residual symptom in antidepressant treatment responders.
• This residual insomnia increases the risk of relapse.
• Disturbed sleep increases pain severity
• Six studies show that insomnia is a risk factor for major depressive disorder

Stress, environment (cold, noise, new baby), acute illness, or pain;

May develop after a period of sleep disruption from stress, infant care, medical illness, pain, or psychological stress.

• Caffeine: sources and effects
• Nicotine
• Role of exercise
• Light bedtime snack (milk, peanut butter)
• Alcohol, tobacco, and other substances
• Environment: light, noise, temperature

• Go to bed only when sleepy
• Use the bed only for sleeping – do not read, watch TV, or eat in bed
• If unable to sleep, move to another room. Stay up until really sleepy. The goal is to associate the bed with falling asleep quickly
• Repeat tactic immediately above as often as necessary
• Awaken at the same time every morning regardless
• of total sleep time
• Do not nap

• Most Effective
• Cut bedtime to actual amount patient reports sleeping, but not <4 hours/night
• Prohibit sleep outside of these hours
• Have patient report daily the amount of sleep obtained
• Compute sleep efficiency (SE); based on moving average of 5 nights, when SE is >85%, increase bedtime by 15 minutes
• With the elderly, SE cutoff is 80%.
• Allow a 30-minute nap

• Identify dysfunctional attitudes and beliefs about sleep
• Explore the validity of self-statements about sleep
• Replace dysfunctional attitudes and beliefs about sleep with more appropriate self-statements
• Schedule Worry time
• Remove thoughts and general cognitive activation away from bedtime and moves them to a better period of the day
• Write down thoughts (brainstorm)
• Order priorities for attention
• Develop problem-solving strategies
• Regular practice is important (be proactive)

• Benzos and Non-Benzos Enhance GABA Inhibition
• GABA is the predominant inhibitory transmitter
• Benzodiazepines and Non-Benzodiazepines bind to a site on the GABA receptor complex and enhance GABA inhibition of arousal systems, tipping scale towards sleep
• Benzodiazepines: Triazolam, Flurazepam, Temazepam, Clonazepam, Alprazolam, Diazepam, Lorazepam
• “Non-benzodiazepines”: Zolpidem, Zaleplon, Eszopiclone
• Dose-Dependent Adverse Effects: Cognitive impairment, Psychomotor impairment, Abuse potential, Daytime Sedation dependent upon pharmacokinetics

• Enhance sleep via activating sleep promoting melatonin system
• Melatonin shifts circadian rhythm but has little effect on sleep onset or maintenance
• Ramelteon: More potent MT1 and MT2 receptor agonist than melatonin
• MT2 receptor associated with phase shifting
• MT1 receptor associated with effect on sleep onset
• Ramelten: No dose dependence for therapeutic or adverse effects
• Melatonin may be associated with a decrease in fertility

• Block wake-promoting effects of HA and Ach shifting balance towards sleep and decreasing arousal
• Little data supporting efficacy
• May have more benefit on maintenance than onset
• Potential Adverse Effects
• Daytime Sedation
• Anticholinergic Side-effects

• Block action in wake-promoting systems shifting balance towards sleep and decreasing arousal
• Few placebo-controlled trials in insomnia patients
• Dose-Dependent Adverse Effects
• Anticholinergic Side-effects: Tricyclic Antidepressants, Mirtazapine
• Orthostatic Hypotension: Tricyclics, Trazodone
• Weight Gain: Tricyclics, Mirtazapine
• Sexual side-effects: Tricyclics, Mirtazapine

• Block action in wake-promoting systems shifting balance towards sleep and decreasing arousal
• No placebo-controlled trials in insomnia patients
• Potential Adverse Effects
• Daytime Sedation
• Weight gain/metabolic syndrome
• Extrapyramidal side-effects (Primarily with “typical” antipsychotics): Acute dystonic reactions, Akathisia, Parkinsonian symptoms, Tardive dyskinesia
• Anticholinergic Side-effects: Primarily with “typical” antipsychotics

• Enhancing activity in sleep promoting systems tilts balance towards sleep
• Potential insomnia therapy Example: Benzodiazepines
• Blocking activity in sleep promoting systems tilts balance towards waking
• Potential therapy for excessive daytime sleepiness Example: Caffeine

• Blocking wake promoting systems tilts balance towards sleep
• Potential insomnia therapies Example: Antihistamines
• Enhancing activity in wake promoting systems tilts balance towards wake
• Potential therapy for disorders of excessive sleepiness Example: Amphetamines

• Whether to treat, what to use, and when to stop should be based on Risk/Benefit assessments.
• This should include the risks of no treatment.
• Greater functional impairment motivates treatment.
• Should take into account the known risks and expected benefits of all treatment options based on placebo-controlled trials in the population of interest
• Institute plan for periodic trial discontinuations
• No consensus about how often – every 3 months?
• Otherwise, there is no way to determine how long to treat

• Common waking sensory-motor disorder
• Clinical Diagnosis based on self-report
• Characterized by delayed sleep onset due to intense restlessness and unpleasant sensation felt deep within the lower parts of the legs that is often described as “electric shock feelings”, “creepy-crawly”, “jittery”
• Prevalence ~10% of the general population, with 1/3 requiring medical intervention
• Prevalence twice as high in women vs. men, and increases with age, with onset usually in 40-50 yrs
• Primary (Idiopathic) RLS: Associated with younger age of onset, Positive family history
• Secondary RLS: Iron deficiency in the CNS, dx with low ferritin level
• Pregnancy (esp. 3rd trimester), ESRD,
• Rarely: Peripheral Neuropathies, Parkinson’s disease, Rheumatoid Arthritis, Diabetes, Hypothyroidism/Hyperthyroidism, Chronic Lung Disease, Huntington’s chorea, ALS

• Around 80% of patients with RLS have frequent, involuntary, rhythmic muscular jerks, during sleep that is noted on polysomnography (PSG)
• Movements are often: Dorsiflexion of the toes, flexion of the ankles, knees, and thighs, Greater than 10 events/hr with arousals tends to be associated with symptoms
• Sleep Related Disorders: Insomnia/Hypersomnia, Narcolepsy, REM Sleep Behavior Disorder (RBD), Obstructive Sleep Apnea (OSA)
• Non-Sleep Related Disorders: Alcohol Dependency, Essential Hypertension (HTN), ESRD, Iron Deficiency
• Role of Iron in Pathophysiology: Link to Dopamine, ↓ in CSF ferritin, (<50 % μg/L) which indicates low CNS iron levels. Iron has circadian variation, with as much as a 50% drop of serum iron levels at night. Iron is a cofactor for tyrosine hydroxylase, which is the rate-limiting enzyme for dopamine synthesis and dopamine receptor regulation

• SSRIs
• TCAs
• Lithium
• Mirtazapine
• Antihistamines
• Dopamine Antagonists
• Calcium Channel Blockers
• Caffeine
• Alcohol

• Dopamine Agonists (pergolide, pramipexole, ropinirole)
• Efficacy well-established
• Levodopa/Carbidopa: Levodopa is a precursor of dopamine which crosses the blood brain barrier and is converted to dopamine. It is combined with carbidopa because it inhibits the peripheral conversion of levodopa to dopamine, thereby increasing the CNS bioavailability of levodopa. Efficacy well-established.

• Carbamazepine: Sodium channel blocker developed as an anticonvulsant. Efficacy demonstrated in RLS but not PLMs
• Clonazepam: Benzodiazepine with therapeutic effect on PLMs; RLS effect less established. Unclear if benefit derives from sedation or direct PLM effect
• Gabapentin: Thought to have effect via blocking calcium channels. Has therapeutic effect on RLS; Effect not demonstrated for PLMs
• Clonidine: Alpha-2 adrenergic agonist. The alpha 2 receptor is an inhibitory presynaptic adrenergic autoreceptor. Has therapeutic effect on RLS; Effect not demonstrated for PLMs

• A self-sustained rhythm observed in nearly all species; Synchronizes organ systems to optimal phase relationships; Entrains organism with environmental Light/Dark cycle.
• Melatonin is high during the night and low during the day when under constant dim light conditions.

• Melatonin is Produced by Pineal during “Biological Night”; -Light Suppresses Melatonin Production via Retinohypothalamic Tract (RHT)
• Key SCN Neurotransmitters: Melatonin, Histamine, Serotonin, GABA, Glutamate
• Circadian Rhythm Regulation is Under Genetic Control
• Inhibition of protein synthesis eliminates circadian cyclicity
• The SCN controls rhythms via generating oscillations at the neuronal level in activity based on function of a small number of proteins.

• Heart (blood circulation)
• Brown adipose tissue (temperature regulation)
• Kidney (electrolyte balance)
• Liver (glucose metabolism)
• Pancreas (glucose stability)
• Adrenal cortex (corticosteroid release)
• White adipose tissue (leptin release, energy storage)

• Delayed Sleep Phase Syndrome
• Advanced Sleep Phase Syndrome
• Irregular Sleep Phase
• Non-24 Hour Circadian Rhythm
• Shift-Work Sleep Disorder
• Jet-Lag
• Treatment: Light Therapy, Melatonin Therapy, Behavioral Modification Program

• Apnea is defined as an arrest of breathing for 10 seconds or more during sleep.
• The primary pathology results from associated arousals and oxygen desaturation.
• Diagnosis requires sleep study
• Two types: Obstructive and Central

• Mechanical upper airway block
• Affects 4% of middle aged men and 2% of middle-aged women Incidence increases with age.
• Roughly 10-23% of people snore which is on a continuum with obstructive apnea.
• Clinical cutoff varies from 5-15 respiratory events (apneas + hypopneas) per hour of sleep.

• Typically obese or have predisposing upper airway anatomy (e.g. large tonsils, retrognathia, deviated septum)
• Significant Hypersomnolence/Fatigue
• LOUD Snoring
• Morning Headache
• Morning Dry Mouth
• Bed partner observes apneas

• Nocturnal Enuresis
• Hypertension
• Polycythemia
• Impotence
• Depression Symptoms or predisposition to treatment refractoriness
• Cardiac Arrhythmias
• Cor Pulmonale
• Death (rarely)

• Diagnosis requires polysomnogram
• Weight Loss
• Position Training
• Eliminate Sedating Medications if Possible
• Treat COPD and allergies
• Treat anatomical defects surgically

• Most commonly prescribed treatment.
• Highly effective.
• Dosed with a pressure titration procedure.
• Major limitation is compliance. Nasal congestion, claustrophobia, general discomfort are the most common problems.
• Some individuals are left with residual symptoms.

• Modafinil FDA approved for daytime sleepiness in those treated with CPAP with residual symptoms.
• UPPP
• Maxillo-mandibular surgery
• Dental Appliances
• Nerve Stimulators?
• Meds?

• CNS based
• No attempt to breathe

• A disorder of REM
• Relatively Rare: Prevalence up to 0.05%
• Cardinal Features: Excessive Daytime Sleepiness, Cataplexy, Sleep Paralysis, Hypnogogic/Hypnopompic Hallucinations
• Diagnostic Characteristics: Cataplexy is single most specific symptom, Sleep Attacks are typical, Brief Naps (include dreams, are restorative), Onset in teen years, Tends to run in families, Characteristic HLA marker, Diagnosis requires sleep study with next day multiple sleep latency (4-5 nap) test
• MSLT: 4 naps with avg. sleep latency < 5 min, and REM in 2 or more naps.
• Pathophysiology Hypotheses: HLA link suggests that Narcolepsy is an auto-immune disease. Genetic absence of hypothalamic hypocretin/orexin neurons. Autoimmune destruction of hypothalamic hypocretin/orexin neurons. Environmental destruction of hypothalamic hypocretin/orexin neurons.
• Treatment: Timed Naps may help sleepiness, Stimulants for Daytime Sleepiness (Modafinil, Methylphenidate, D-amphetamine). For REM related symptoms use REM suppressant medications (Clomipramine (Anafranil), SSRIs). Sodium Oxybate (Xyrem) is now FDA-approved for the treatment of daytime sleepiness, insomnia and cataplexy associated with narcolepsy. It appears to be the most effective agent for cataplexy. Because of its potential for abuse, access is limited to prevent off-label use.

• Short-term goals: Reduce severity and duration of symptoms, Improve functioning
• Long-term goals: Achieve symptom remission, Facilitate patient’s return to pre-morbid level of functioning, Reduce length of episodes, Reduce severity of episodes, Prevent recurrence

• Benzodiazepines: First-line treatment
• SSRIs: First-line treatment
• SNRIs: First-line treatment
• Buspirone (BuSpar)
• Other agents: Hydroxyzine, imipramine, and propranolol

• Located in every region of the brain
• Consists of GABAA and GABAB receptors
• GABAA receptors produce inhibitory effect on CNS
• GABAB receptors produce inhibitory effect on GABA release
• GABAA receptors are made up of five peptide subunits
• Binding of GABA: Chloride ion channel open and influx of chloride ions. Hyper-polarization and reduced firing of the neuron
• Expression of GABA receptors may fluctuate over time and in response to stress

• SSRIs, SNRIs, TCAs, phenelzine, and buspirone: Effect may not be seen until four to six weeks
• Benzodiazepines: Effect may be seen as early as days to one week
• Adequate trial: Considered six to eight weeks
• Acute phase: A period of one to three months. Majority of response.
• Maintenance phase: A period of one to two years. Maintain at lowest effective dose. Taper drug over four to six months

• Efficacy Parameters: reduction of anxiety (frequency, duration, severity), improvement in functioning
• Time Points: acute (twice weekly); maintenance (once a month)
• Safety Parameters / Time Points
• side effects: evaluate at each follow up appointment
• BZ/buspirone: no recommended lab monitoring
• beta blockers: HR, BP
• AD: (same as depression)

• Options (FDA approved): Alprazolam (Xanax), Chlordiazepoxide (Librium), Clonazepam (Klonopin), Clorazepate (Tranxene), Diazepam (Valium), Lorazepam (Ativan), Oxazepam (Serax)
• MOA: Potentates inhibitory effect of GABA, BZ-GABA receptor complex, Increases the opening of the chloride ion channel
• Side Effects (Varying degrees of lipophilicity): Affects ability to cross the blood-brain barrier. May produce rapid onset of action. Experience rush of euphoria. Unpleasant feeling/loss of control
• CNS depression: Sedation (most common). Drowsiness, ataxia, or psychomotor impairment. Aggression, irritability, or excitement.
• Impairment of memory or recall: Anterograde amnesia
• Abuse: Abuse unlikely in general population
• Dependence: Characterized by withdrawal symptoms, Onset varies with half-life of benzodiazepine, Anxiety, insomnia, restlessness, muscle tension, and irritability

• Treatment of choice for acute anxiety relief
• Produce effects within days to one week
• Produce additional benefit on sleep and muscle relaxation
• Lorazepam and oxazepam: Patients with liver dysfunction, Slower onset of effect
• Diazepam: Non-compliance, avoidance of withdrawal symptoms. Disadvantages: Less robust evidence for long-term treatment, Long-term sedation and cognitive impairment, Withdrawal syndromes and dependence, Caution use in patients with comorbid substance abuse

• Mild Symptoms: drowsiness, confusion, somnolence, impaired coordination, diminished reflexes, lethargy
• Serious (rare): ataxia, hypotonia, hypotension, hypnosis, coma, death
• Treatment: gastric lavage, supportive measures, flumazenil

• Physiologic phenomenon occurring when BZ removed too quickly
• Rebound symptoms = immediate return of original symptoms, sometimes with higher intensity
• Lasts days-weeks; resolves over several months
• Common symptoms: anxiety, restlessness, insomnia, agitation, muscle tension, irritability
• More likely in users of high doses for long periods of time
• Taper over several weeks when discontinuing!!

• Second-line treatment, augmentation
• MOA: Partial agonist at 5-HT1A pre- and post-synaptic receptors
• Side effects: Lack of sedation and anxiolytic properties are major advantages, Dizziness, nausea, and headache, Minimal drug interactions
• Dosing: initiate 5mg po TID; target dose 20-30mg/day; maximum dose 60mg/day; always with or without food, ­ bioavailability with food
• No immediate anxiolytic effect: initial clinical effect 1 week, maximum benefit 4-6 weeks
• Use in GAD: current/history of substance abuse, intolerant to BZ therapy, refractory GAD, Less sedation and functional impairment than BZ
• Metabolized by CYP3A4

• Second-line treatment, augmentation
• MOA: Potent antihistaminergic, anticholinergic, and antispasmodic effects
• Side effects: GI, headache, sedation, and minimal drug interactions

• Second-line treatment
• MOA: Blocks reuptake of 5-HT and NE
• Side effects: Anticholinergic, sedative, cardiovascular, and CNS

• MOA (anxiolytic): blockade of postsynaptic beta receptors results in decrease of autonomic symptoms
• Response seen within 1 week
• Taper when discontinuing
• Use in GAD: Good for patients with prominent CV symptoms (palpitations, tremors), adjunctive therapy for refractory GAD

• SSRI: First-line treatment recommendation, All SSRIs are considered effective (FDA approval – fluoxetine, sertraline, paroxetine). Start at half initial starting dose, increase every 3-7d
• SNRI: Venlafaxine ER, First-line treatment recommendation, FDA approved, Demonstrated efficacy, Recommend to start at half initial starting dose. Maintain dose for 3 to 7 days before titrating
• TCA: Second-line treatment recommendation. Efficacy with imipramine, desipramine, clomipramine, nortriptyline. Patients my be more sensitive to the adverse effects. Imipramine (Dose at 100mg/day, treat for 4 weeks before adjusting) or Clomipramine (Benefit with clomipramine over imipramine in 1 trial). Equal efficacy in comparator trials with SSRIs
• Benzodiazepines: Alprazolam and extended release FDA approved. Equal efficacy with imipramine, benefit in agoraphobia. Clonazepam. Diazepam, lorazepam may be effective in equal doses. Augmentation of antidepressants produces more rapid response
• Other Treatment Options: Monoamine Oxidase Inhibitors (No studies in panic); Bupropion, trazodone, mirtazapine (no data). Beta-blockers, buspirone INEFFECTIVE. Possibility of mood stabilizers and antipsychotics as adjunctive agents.

• Treatment options: CBT, SSRIs, Clomipramine, Other antidepressants, Atypical antipsychotics, Memantine
• Response to treatment: 65% to 75% respond to first OCD treatment (SSRI). Up to 90% will respond to continued medication trials. Adequate medication trial is 8 to 12 weeks, Max dose for 4-6 wks. 1st episode treat for 1 – 2 yrs; lifelong w/repeated episodes. Treatment failure is less than a 25% reduction in baseline SXs. Clomipramine -> second-line treatment option. Combination Tx -> SSRI + clomipramine, atypical antipsychotic. Lifelong Tx -> 2 to 4 severe relapse; 3 to 4 mild relapses .

• SSRIs: are first line treatment recommendation.
• FDA approval: fluoxetine, sertraline, paroxetine, fluvoxamine
• FDA approval in children: fluoxetine, sertraline, fluvoxamine
• SSRI’s vs clomipramine show comparable efficacy
• Clomipramine: is 2nd line.
• Use following 2-3 failed SSRI trials
• FDA approved -> children and adults
• Side effects -> typical to TCAs
• Caution in pts. with hepatic or cardiovascular disease, elderly, pregnancy
• Venlafaxine: Mixed findings. No benefit compared to placebo. Possible worsening of symptoms
• Mirtazapine: Efficacious compared to placebo.
• Phenelzine: Comparable efficacy to clomipramine. Less effective than fluoxetine
• Atypical antipsychotics: Augmentation for partial SSRI responders. Studies showed efficacy in SSRI refractory patients. Efficacious (risperidone, olanzapine, haloperidol). Mixed (quetiapine).
• Memantine (Nameda): Augmentation to standard of care

• Response to treatment: Tx should be started immediately following onset of SXs. Response to Tx may be slow. Adequate medication trial is 8 to 12 weeks Max dose for 4-6 wks. 1st episode treat for 1 – 2 yrs; lifelong w/repeated episodes.
• CBT: desensitization, Mild SXs; combination w/antidepressant for mod-to-severe SXs. Benefit w/in 3 to 6 months following trauma
• SSRIs: First-line treatment options. Sertraline and paroxetine are FDA approved for acute Tx. Sertraline is FDA approved for long-term (52 wk) Tx. All SSRIs are used in Tx. Clinical studies showed benefit on arousal and avoidance/numbing but not on re-experiencing .
• venlafaxine, mirtazapine: 2nd line
• TCAs, MAOIs: 3rd line
• Bupropion SR: ineffective
• Atypical antipsychotics, prazosin: Benefit only when added to SSRI

• Use lowest initial dose
• Treat for at least 12 months following symptoms remission
• Long-term treatment: 3 or more episodes, 2 episodes in 5 yrs
• Melancholic depression: benefit seen with TCAs, possible role of venlafaxine, mirtazapine
• Psychotic depression: combination of antidepressant + antipsychotic

• Fluoxetine (Prozac)
• Sertraline (Zoloft)
• Citalopram (Celexa)
• Escitalopram (Lexapro)
• Paroxetine (Paxil)
• Fluvoxamine (Luvox)
• MOA: Selectively inhibit the reuptake of 5-HT by blocking the 5-HT transporter. Citalopram and paroxetine are the most potent 5-HT uptake blockers. Fluoxetine and paroxetine (doses > 40mg) produce effect on NE. Sertraline effect on DA may be as/more potent than bupropion. Paroxetine has greatest anticholinergic activity.
• GI Side Effects: Effect on 5-HT receptors (mainly 5-HT3) in gut. Most common reason for early discontinuation. Diarrhea, nausea, bloating, cramping, and heartburn. Diminishes after 2–4 wks. Start low and titrate slowly and take with meals.
• CNS Side effects: Effect on 5-HT receptors causing CNS arousal. Insomnia, akathisia, agitation, tremor, headache. Tremor may be dose related. Akathisia greatest with fluoxetine. Most intense at start of therapy. Start low and titrate slowly. Dose early in the day. Benzodiazepine (BZ)-> low dose, twice daily. Trazodone at dose of 25-100mg for insomnia. Low dose propranolol for akathisia, tremor.
• Sexual Dysfunction Side Effects: Delayed ejaculation, anorgasmia, impotence, and diminished libido. Greatest with paroxetine, least with citalopram. Add sildenafil, switch to bupropion.
• Sedation/Fatigue/Numbness: Sedation greatest with paroxetine Due to anticholinergic properties. Start low and titrate slowly. Give dose in the evening. Add bromocriptine or modafinil or stimulants.
• Dry mouth, increased perspiration, hypotension: Minimal effect on M1 (PRX greatest effect), alpha-1 receptors
• Serotonin syndrome: Seen with the combination of SSRIs and other agents, especially in OD. Manifested as autonomic and neuromuscular responses. Hyperreflexia, tremor, GI complaints, CV problems, seizures, reparatory depression, coma, death.
• Withdrawal: Nightmares, flu-like symptoms, GI, shock-like sensations, and insomnia. Seen usually in 2 to 7 days after abrupt discontinuation. Taper slowly over a period of weeks. May be less with fluoxetine, greatest with paroxetine are sertraline. Switch to fluoxetine
• Overdose: Safe, common sxs include nausea, vomiting, tremor, and sedation. Most worrisome in combination with other agents-> serotonin syndrome. Complications related to status epilepticus or arrhythmias .

• Fluoxetine
• Effective dose range 20-40mg/day
• Benefit possible up to 60mg/day (Increased side effect burden)
• Possible benefit in reduced dosing due to long half-life
• Most activating
• Beneficial in pts. with sedation, fatigue, or decreased energy
• Problematic in pts with anxiety, agitation, or insomnia
• Benefit in comorbid conditions-> anxiety d/o, PMDD, eating d/o
• Benefit in non-compliant patients due to increased half-life
• Lowest weight gain of SSRIs
• Avoid in patients taking medications metabolized by CYP 2D6

• Effective dose range is 30-50mg/day
• Less activating
• Beneficial in pts complaining of anxiety, agitation, or insomnia
• Problematic in pts with sedation, fatigue, or decreased energy
• Weight gain may be greatest of SSRIs
• Increased sexual dysfunction
• Avoid in patients taking medications metabolized by CYP 2D6

• Effective dose range for CIT 20-60mg/day, LEX 10-20mg/day
• Side effects of CIT 40mg seen at LEX 20mg
• Few drug interactions
• Lower risk of sexual side effects with citalopram
• Easy titration with escitalopram

• Venlafaxine IR & XR (Effexor)
• Duloxetine (Cymbalta)
• Desvenlafaxine (Pristiq)
• MOA: Block the reuptake of 5-HT and NE and to a lesser extent DA
• Venlafaxine only produces effects on NE at a higher dose
• Duloxetine has a high level of effect on both 5-HT and NE
• Low affinity for histamine- 1, alpha-1, or muscarinic receptor
• Side Effects: Duloxetine side effect profile may be less severe than venlafaxine. XR formulation of venlafaxine helps to diminish side effects. GI, HTN, Nervousness, sweating, insomnia, sexual dysfunction, dry mouth, constipation, withdrawal, overdose rare but can be fatal.

• Amitriptyline (Elavil)
• Clomipramine (Anafranil). Not FDA approved for depression, FDA approved for OCD
• Desipramine (Norpramin)
• Doxepin (Sinequan). FDA approved for mixed anxiety and depressive disorder
• Imipramine (Tofranil)
• Nortriptyline (Pamelor). Recommended for use in post-stroke depression
• MOA: Block the reuptake of 5-HT and NE to varying degrees. First generation TCAs produce a greater effect on 5-HT reuptake. Second generation TCAs produce a greater effect on NE reuptake.
• Anticholinergic Side Effects: Dry mouth, Constipation, Urinary Hesitancy, Esophageal reflux
• Cardiovascular Side Effects: Orthostatic hypotension, Tachycardia, Cardiac conduction problems, Hypertension
• CNS Side Effects: Tremor, Sedation, Stimulation, Myoclonic twitches
• Other Side Effects: Weight gain, Sexual dysfunction, Decreased seizure threshold. Start at a low dose and titrate slowly, switch to a less offensive agent. Bethanechol for anticholinergic side effects. Lethal in overdose

• Phenelzine (Nardil)
• Tranylcypromine (Parnate)
• Selegiline (Emsam)
• MOA: Block the destruction of monoamines by pre-synaptic neuronal MAO. Produce effect both centrally and peripherally. MAO-A acts largely on NE and 5-HT. MAO-B acts largely on phenylethylamine and dopamine.
• Irreversible MAO-Is: Phenelzine (Nardil) and tranylcypromine (Parnate). Non-selective for both MAO-A and MAO-B. Produce a greater effect on MAO-A
• Reversible MAO-Is: Selegiline (Eldepryl/Emsam). Only selegiline patch FDA approved for depression. At low doses has effect only on MAO-B, at high doses effects both.
• Side Effects: Weight gain, Rash -> selegiline patch, Orthostasis, Sexual dysfunction, Insomnia, somnolence, Headache, Anesthetics , Lethal in overdose, Hypertensive crisis, stroke, and MI have all been reported
• Dietary precautions: Greater worry with MAO-A inhibitors. Increased dietary concerns with increased doses of selegiline patch.

• Mirtazapine (Remeron)
• Bupropion (Wellbutrin)
• Trazodone (Desyrel)

• MOA: Blocks central alpha-2 auto/hetero-receptors increasing NE and 5-HT
• Side effects: Somnolence (Seen with lower doses), Weight gain/increased appetite in ~ 20% of patients (Treat with diet and exercise. May lead to increases in cholesterol and triglycerides). Orthostatic hypotension, dizziness, and dry mouth, Agranulocytosis (Initial worry, not seen often clinically )

• MOA: Weak reuptake inhibitor of NE and DA. Effect on DA may be less than sertraline. Indirect low effect on 5-HT. Active metabolite hydroxybupropion has amphetamine properties . Potent reuptake inhibitor of both NE and DA. Low affinity for histamine- 1, alpha-1, or muscarinic receptors
• Lowered seizure threshold: Risk of seizure ~ 0.4% at doses < 450 mg and 4% at doses > 450 mg. Risk of seizure with SR formulation is 0.1% with doses < 400 mg. Risk greater with prior seizure d/o, head injury, bulimia, anorexia
• Other side effects: Insomnia, nervousness, agitation, anxiety, and tremor. Vivid nightmares, delusions, and psychosis

Side effects: GI upset, Sedation, orthostatic hypotension, priapism, and dry mouth, Hepatic dysfunction

• Good option for patients with decreased appetite or weight loss
• Good option for patients with insomnia, anxiety, and agitation
• Sedative effect decreases with higher doses
• Decreased prevalence of nausea and sexual dysfunction
• Good adjunct therapy to SSRIs for sexual dysfunction
• Safe in overdose

• Trazodone needs a dose >150 mg for antidepressant effect
• Good option for patients with insomnia
• Trazodone only -> dose of 25-100mg
• Good adjunctive therapy to other antidepressants
• m-CPP ->anxiogenic properties, caution with CYP-2D6 inhibitors
• Orthostasis common with trazodone, common in elderly
• Priapism -> rare occurrence, common with trazodone due to alpha-1
• GI upset -> less than SSRIs, common reason for d/c
• Less sexual dysfunction, less concerns with overdose and withdrawal
• Lessened withdrawal effects, concern over rebound insomnia
• Avoid nefazodone in patients with liver dysfunction

• Effective dosage range 200 – 450mg/day
• Dose earlier in the day, 8hr dose separation
• Excellent adjunct treatment for SSRI sexual side effects
• Good option for patients with complaints of sedation and fatigue
• Good option for patients with complaints of sexual dysfunction
• Good option for seasonal affective d/o, ADHD, bipolar spectrum d/o
• Problematic for pts with anxiety d/o. Too activating
• Problematic in patients with pre-existing seizure or eating disorder
• Overdose-> concern over seizure risk

• Treatment strategies
• General findings: 6 wks is necessary for patients to achieve a response. Pts. unable to tolerate medication preferred switch. Pts. able to tolerate medication preferred augmentation.
• Second stage: Switching within class, out-of-class, dual-acting agent had same results. Bupropion-SR produced better results than buspirone. Substantial pharm. differences didn’t mean substantial results.
• Third stage: Low remission rates, different pharm. MOA didn’t give great results. T3 better tolerated compared to lithium.
• Fourth stage: Difficulty using tranylcypromine, modest benefit with venlafaxine + mirtazapine

• Sufficient trial is around 2 - 4 weeks
• Continue therapy for 12 mo
• Taper over several months
• Consider long-term therapy: Two manic episodes, One severe manic episode, Strong family history, One episode or more a year, Rapid onset of mania
• Treatment Options: Lithium, Anticonvulsants, Atypical antipsychotics, Antidepressants, Miscellaneous medications

• Any history of depression?
• Recent sadness?
• Sleep disturbance?
• Anhedonia?
• Suicidal/homicidal ideation?
• Loss of libido?
• Anxiety?
• Hallucinations?
• Delusions?
• Behavioral changes?

• Sleep disorder
• Interest deficit (anhedonia)
• Guilt (worthlessness / regret)
• Energy deficit
• Concentration deficit
• Appetite disorder (decreased or increased)
• Psychomotor retardation
• Suicidality

• 1. Have you ever felt you should cut down on your drinking?
• 2. Have people annoyed you by criticizing your drinking?
• 3. Have you ever felt bad or guilty about your drinking?
• 4. Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eye-opener)?
• 2 or more positive responses indicate that you may have a problem with alcohol

• 22 questions, including:
• Do you feel you are a normal drinker? (“normal” – drink as much or less than most other people)?
• Have you ever awakened the morning after some drinking the night before and found that you could not remember a part of the evening?
• Does any near relative or close friend ever worry or complain about your drinking?
• Can you stop drinking without difficulty after one or two drinks?

• 1. Do you feel you are a normal drinker?
• 2. Do your spouse or parents worry or complain about your drinking?
• 3. Do you ever feel bad about your drinking?
• 4. Do friends or relatives think you are a normal drinker?
• 5. Are you always able to stop drinking when you want to?
• 6 . Have you ever attended a meeting of Alcoholics Anonymous?
• 7. Has drinking ever created problems between you and your spouse?
• 8. Have you ever gotten into trouble at work because of drinking?
• 9. Have you ever neglected your obligations, your family, or your work for 2 or more days in a row because you were drinking?
• 10. Have you ever gone to anyone for help about your drinking?
• 11. Have you ever been in the hospital because of drinking?
• 12. Have you ever been arrested even for a few hours because of drinking?
• 13. Have you ever been arrested for drunk driving or driving after drinking?
• 3 or more positive responses- you may have a problem with alcohol

• SCOFF Questionnaire
• Indications: Eating Disorder Screening
• Questions
• Make yourself SICK when you feel uncomfortably full?
• Worry you have lost CONTROL over how much you eat?
• Recently lost more than 14 pounds within three months?
• ONE stone's worth of weight
• Believe you are FAT when others say you are too thin?
• Would you say that FOOD dominates your life?
• Interpretation
• Score one point for each question answered 'yes' above
• Two or more points suggests eating disorder

• A common way of responding to stress
• Psychological distress expressed as physical symptoms
• Frequently seen in non-psychiatric settings: 20-35% of primary care visits
• Most patients with somatic symptoms do not have a true somatoform disorder
• Increased iatrogenic complications
• More procedures, polypharmacy
• “Pseudoseizure” pts: most common cause of morbidity/mortality is misdiagnosis of epilepsy

• A masked presentation of psych dx
• A response to the incentives of the health care system
• Providers often ignore psychosocial aspects of complaints, reinforce somatization of pts
• Amplifying perceptual styles

• Hypervigilance to bodily sensations
• Pts concentrate on weak or infrequent bodily sensations
• Reaction to sensations with cognitions that intensify them and make them more alarming
• Often seen in patients who have or have had true, serious illnesses

• Physical and sexual abuse associated with somatization
• Increased trauma hx in pts with pseudoseizures
• 67% sexual abuse, 67% physical abuse
• Increased somatization in communities after natural disasters
• Increased somatization in combat-related PTSD

• Stigmatization of psychiatric distress may promote somatization
• Physical illness considered more real, less associated with blame, pts more likely to report somatic sxs
• Somatic sxs reinforced over psychological sxs

• Absence of gold standard for diagnosis
• No clear pathophysiologic mechanism
• Lab and physical assessments are unrevealing
• Often respond to psychologic and psychopharmacologic interventions
• Emergence of patient advocacy groups

• Allergy: Food allergies, sick building syndrome
• GI: IBS, chronic abdominal pain
• ID: Chronic lyme
• Neurology: non-epileptiform spells
• OB/Gyn: Chronic pelvic pain, dyspareunia
• Rheumatology: CFS, fibromyalgia

• Many different organ systems involved
• Comorbid anxiety or depression
• Sx lead to psychological gain
• Fluctuating course
• Chronicity
• Idiosyncratic response to medications

• Presence of sx or deficits that affect voluntary motor or sensory function in a way that suggests neurological condition.
• Medically unexplainable
• Initiation preceded by psychological stress
• Causes significant distress, not feigned
• Not limited to pain or sexual dysfunction
• Tend to be highly suggestible
• “La belle indifference”
• All ages, remits and recurs
• Most common somatoform disorder
• 5-16% of psych consults
• Gender bias 2-10:1 women: men
• Related to dissociative disorders

• Physical complaints must begin before the age of 30, and occur over several years
• Four pain sx
• Two non-pain GI sx
• One sexual sx
• One pseudoneurological sx
• Sx have been appropriately medically investigated
• Sx are neither intentionally produced or feigned

• Preoccupation with fears of having, or the idea that one has, a serious disease based on one’s misinterpretation of bodily symptoms
• Persists despite appropriate medical evaluation and reassurance
• Preoccupation causes significant distress or impairment
• Lasts at least six months

• Preoccupation with imagined defect in appearance
• Prevalence estimated at 1-2% of population
• Affects men and women with near equal frequency
• Recommended Medication: SSRIs
• Doses need to be higher than those used to treat depression; similar to those used to treat OCD
• Atypical antidepressants, antipsychotics, benzodiazepines, tricyclics, mood stabilizers not empirically supported
• Counseling: Cognitive behavioral therapy, Behavior modification strategies

• Pain in one or more anatomic sights is predominant focus of clinical presentation
• Not intentionally produced or feigned
• Psychological factors are judged to have important role in onset, exacerbation, severity, or maintenance of pain
• May or may not be associated with a general medical condition

• Negative or distorted cognition, such as feeling helpless or hopeless with respect to pain and its management
• Inactivity, passivity, and/or disability
• Increased pain requiring clinical intervention
• Insomnia and fatigue
• Disrupted social relationships at home, work, or school
• Depression and/or anxiety

• Goal is to produce or feign signs of medical or mental disorder and assume patient role
• Not seeking financial or legal gain
• Often have medical background
• Prevalence is not known
• Comorbidity with borderline personality disorder

• Intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives
• Ex – Obtain disability, avoid military duty, obtain narcotics, obtain financial compensation, avoid work
• Not considered a mental illness by the DSM IV-TR

• A. A history of many physical complaints beginning before age 30 years that occur over a period of several years and result in treatment being sought or significant impairment in social, occupational, or other important areas of functioning.
• B. Each of the following criteria must have been met, with individual symptoms occurring at any time during the course of the disturbance:
• 1. four pain symptoms: a history of pain related to at least four different sites or functions (e.g., head, abdomen, back, joints, extremities, chest, rectum, during menstruation, during sexual intercourse, or during urination)
• 2. two gastrointestinal symptoms: a history of at least two gastrointestinal symptoms other than pain (e.g., nausea, bloating, vomiting other than during pregnancy, diarrhea, or intolerance of several different foods)
• 3. one sexual symptom: a history of at least one sexual or reproductive symptom other than pain (e.g., sexual indifference, erectile or ejaculatory dysfunction, irregular menses, excessive menstrual bleeding, vomiting throughout pregnancy)
• 4. one pseudoneurological symptom: a history of at least one symptom or deficit suggesting a neurological condition not limited to pain (conversion symptoms such as impaired coordination or balance, paralysis or localized weakness, difficulty swallowing or lump in throat, aphonia, urinary retention, hallucinations, loss of touch or pain sensation, double vision, blindness, deafness, seizures; dissociative symptoms such as amnesia; or loss of consciousness other than fainting)
• C. Either (1) or (2):
• 1. after appropriate investigation, each of the symptoms in Criterion B cannot be fully explained by a known general medical condition or the direct effects of a substance (e.g., a drug of abuse, a medication)
• 2. when there is a related general medical condition, the physical complaints or resulting social or occupational impairment are in excess of what would be expected from the history, physical examination, or laboratory findings
• D. The symptoms are not intentionally produced or feigned (as in Factitious Disorder or Malingering).

• A. One or more symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or other general medical condition.
• B. Psychological factors are judged to be associated with the symptom or deficit because the initiation or exacerbation of the symptom or deficit is preceded by conflicts or other stressors.
• C. The symptom or deficit is not intentionally produced or feigned (as in Factitious Disorder or Malingering).
• D. The symptom or deficit cannot, after appropriate investigation, be fully explained by a general medical condition, or by the direct effects of a substance, or as a culturally sanctioned behavior or experience.
• E. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.
• F. The symptom or deficit is not limited to pain or sexual dysfunction, does not occur exclusively during the course of Somatization Disorder, and is not better accounted for by another mental disorder.

• A. Pain in one or more anatomical sites is the predominant focus of the clinical presentation and is of sufficient severity to warrant clinical attention.
• B. The pain causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• C. Psychological factors are judged to have an important role in the onset, severity, exacerbation, or maintenance of the pain.
• D. The symptom or deficit is not intentionally produced or feigned (as in Factitious Disorder or Malingering).
• E. The pain is not better accounted for by a Mood, Anxiety, or Psychotic Disorder and does not meet criteria for Dyspareunia.

• A. Preoccupation with fears of having, or the idea that one has, a serious disease based on the person's misinterpretation of bodily symptoms.
• B. The preoccupation persists despite appropriate medical evaluation and reassurance.
• C. The belief in Criterion A is not of delusional intensity (as in Delusional Disorder, Somatic Type) and is not restricted to a circumscribed concern about appearance (as in Body Dysmorphic Disorder).
• D. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• E. The duration of the disturbance is at least 6 months.
• F. The preoccupation is not better accounted for by Generalized Anxiety Disorder, Obsessive-Compulsive Disorder, Panic Disorder, a Major Depressive Episode, Separation Anxiety, or another Somatoform Disorder.

• A. Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person's concern is markedly excessive.
• B. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• C. The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in Anorexia Nervosa).

• A.Characteristic symptoms: Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated):
• 1.delusions
• 2.hallucinations
• 3.disorganized speech (e.g., frequent derailment or incoherence)
• 4.grossly disorganized or catatonic behavior
• 5.negative symptoms, i.e., affective flattening, alogia, or avolition
• Note: Only one Criterion A symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person's behavior or thoughts, or two or more voices conversing with each other.
• B.Social/occupational dysfunction: For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, failure to achieve expected level of interpersonal, academic, or occupational achievement).
• C.Duration: Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).
• D.Schizoaffective and Mood Disorder exclusion: Schizoaffective Disorder and Mood Disorder With Psychotic Features have been ruled out because either (1) no Major Depressive, Manic, or Mixed Episodes have occurred concurrently with the active-phase symptoms; or (2) if mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods.
• E.Substance/general medical condition exclusion: The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
• F.Relationship to a Pervasive Developmental Disorder: If there is a history of Autistic Disorder or another Pervasive Developmental Disorder, the additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month (or less if successfully treated).

• A type of Schizophrenia in which the following criteria are met:
• A. Preoccupation with one or more delusions or frequent auditory hallucinations.
• B. None of the following is prominent: disorganized speech, disorganized or catatonic behavior, or flat or inappropriate affect.

• A type of Schizophrenia in which the following criteria are met:
• A. All of the following are prominent:
• 1. disorganized speech
• 2. disorganized behavior
• 3. flat or inappropriate affect
• B. The criteria are not met for Catatonic Type.

• A type of Schizophrenia in which the clinical picture is dominated by at least two of the following:
• 1. motoric immobility as evidenced by catalepsy (including waxy flexibility) or stupor
• 2. excessive motor activity (that is apparently purposeless and not influenced by external stimuli)
• 3. extreme negativism (an apparently motiveless resistance to all instructions or maintenance of a rigid posture against attempts to be moved) or mutism
• 4. peculiarities of voluntary movement as evidenced by posturing (voluntary assumption of inappropriate or bizarre postures), stereotyped movements, prominent mannerisms, or prominent grimacing
• 5. echolalia or echopraxia

• A type of Schizophrenia in which the following criteria are met:
• A. Absence of prominent delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior.
• B. There is continuing evidence of the disturbance, as indicated by the presence of negative symptoms or two or more symptoms listed in Criterion A for Schizophrenia, present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).

• A. Criteria A, D, and E of Schizophrenia are met.
• B. An episode of the disorder (including prodromal, active, and residual phases) lasts at least 1 month but less than 6 months. (When the diagnosis must be made without waiting for recovery, it should be qualified as "Provisional.")

A. An uninterrupted period of illness during which, at some time, there is either a Major Depressive Episode, a Manic Episode, or a Mixed Episode concurrent with symptoms that meet Criterion A for Schizophrenia.

• B. During the same period of illness, there have been delusions or hallucinations for at least 2 weeks in the absence of prominent mood symptoms.
• C. Symptoms that meet criteria for a mood episode are present for a substantial portion of the total duration of the active and residual periods of the illness.
• D. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

• A. Nonbizarre delusions (i.e., involving situations that occur in real life, such as being followed, poisoned, infected, loved at a distance, or deceived by spouse or lover, or having a disease) of at least 1 month's duration.
• B. Criterion A for Schizophrenia has never been met. Note: Tactile and olfactory hallucinations may be present in Delusional Disorder if they are related to the delusional theme.
• C. Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired and behavior is not obviously odd or bizarre.
• D. If mood episodes have occurred concurrently with delusions, their total duration has been brief relative to the duration of the delusional periods.
• E. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
• Erotomanic Type: delusions that another person, usually of higher status, is in love with the individual
• Grandiose Type: delusions of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person
• Jealous Type: delusions that the individual's sexual partner is unfaithful
• Persecutory Type: delusions that the person (or someone to whom the person is close) is being malevolently treated in some way
• Somatic Type: delusions that the person has some physical defect or general medical condition
• Mixed Type: delusions characteristic of more than one of the above types but no one theme predominates
• Unspecified Type

This subtype applies when the central theme of the delusion is that another person is in love with the individual. The delusion often concerns idealized romantic love and spiritual union rather than sexual attraction. The person about whom this conviction is held is usually of higher status (e.g., a famous person or a superior at work), but can be a complete stranger. Efforts to contact the object of the delusion (through telephone calls, letters, gifts, visits, and even surveillance and stalking) are common, although occasionally the person keeps the delusion secret. Most individuals with this subtype in clinical samples are female; most individuals with this subtype in forensic samples are male. Some individuals with this subtype, particularly males, come into conflict with the law in their efforts to pursue the object of their delusion or in a misguided effort to "rescue" him or her from some imagined danger.

This subtype applies when the central theme of the delusion is the conviction of having some great (but unrecognized) talent or insight or having made some important discovery. Less commonly, the individual may have the delusion of having a special relationship with a prominent person (e.g., an adviser to the president) or being a prominent person (in which case the actual person may be regarded as an impostor). Grandiose delusions may have a religious content (e.g., the person believes that he or she has a special message from a deity).

This subtype applies when the central theme of the person's delusion is that his or her spouse or lover is unfaithful. This belief is arrived at without due cause and is based on incorrect inferences supported by small bits of "evidence" (e.g., disarrayed clothing or spots on the sheets), which are collected and used to justify the delusion. The individual with the delusion usually confronts the spouse or lover and attempts to intervene in the imagined infidelity (e.g., restricting the spouse's autonomy, secretly following the spouse, investigating the imagined lover, attacking the spouse).

This subtype applies when the central theme of the delusion involves the person's belief that he or she is being conspired against, cheated, spied on, followed, poisoned or drugged, maliciously maligned, harassed, or obstructed in the pursuit of long-term goals. Small slights may be exaggerated and become the focus of a delusional system. The focus of the delusion is often on some injustice that must be remedied by legal action ("querulous paranoia"), and the affected person may engage in repeated attempts to obtain satisfaction by appeal to the courts and other government agencies. Individuals with persecutory delusions are often resentful and angry and may resort to violence against those they believe are hurting them.

This subtype applies when the central theme of the delusion involves bodily functions or sensations. Somatic delusions can occur in several forms. Most common are the person's conviction that he or she emits a foul odor from the skin, mouth, rectum, or vagina; that there is an infestation of insects on or in the skin; that there is an internal parasite; that certain parts of the body are definitely (contrary to all evidence) misshapen or ugly; or that parts of the body (e.g., the large intestine) are not functioning.

• A.Presence of one (or more) of the following symptoms:
• 1.delusions
• 2.hallucinations
• 3.disorganized speech (e.g., frequent derailment or incoherence)
• 4.grossly disorganized or catatonic behavior

• Haloperidol (Haldol)
• Fluphenazine (Prolixin)
• Perphenazine (Trilafon)
• Thioridazine (Mellaril)
• Chlorpromazine (Thorazine)

• Clozapine (Clozaril)
• Olanzapine (Zyprexa)
• Risperidone (Risperdal)
• Quetiapine (Seroquel)
• Ziprasidone (Geodon)
• Aripiprazole (Abilify)
• Iloperidone (Fanapt)
• Asenapine (Saphris)
• Lurasidone (Lutuda)

• Efficacy: Positive symptoms. Possibly worsen negative symptoms
• D2 receptors: Non-selective antagonists of D2 receptors in all DA tracts. Block 70% to 90% of D2 receptors at clinical doses. 400mg of chlorpromazine blocks > 80%. Increased risk of EPS with high potency typicals. Depolarization block in both A9 and A10 areas. Decrease in synthesis and release of DA. Decreases symptoms, increase EPS
• 5-HT receptors: Chlorpromazine, low potency typicals. High affinity for 5-HT2 receptors. Clinical doses produce saturation of these receptors. Possible effects on negative symptoms.
• Cholinergic receptors: Blockade highest with low potency typicals
• Histaminergic receptors: Blockade highest with low potency typicals

• Main feature of atypicals is diminished EPS and prolactin levels
• Benefit due to lower rates of EPS than on symptom improvement
• Efficacy on Positive symptoms: Better than placebo
• Efficacy on Negative symptoms: Better than placebo, questionable compared to haloperidol
• Efficacy on Mood and cognition: No evidence of direct effect, due to a lessening of EPS
• DA receptors: Attach at the same rate to the D2 receptor as typicals. Quick rate of dissociation from the D2 receptor. Fast dissociation increases response to phasic bursts of DA. Modulation of the DA signal without disruption. Less binding potency and occupancy, lessen side effects
• 5-HT receptors: Increased ratio of 5-HT to DA blockade. Low doses produce significant blockade
• Cholinergic and histaminergic receptors: Variable effect depending on atypical

• Adequate trial: 4-6 weeks for both typicals and atypicals. Chlorpromazine eqv. dosage range between 400 – 600. Clozapine plasma level of 350 – 420 ng/ml
• Treatment length: First episode ->12 mo. following the symptoms remission. Multiple episodes ->5 yrs following symptoms remission
• Slow taper is imperative to preventing acute relapse. Generally recommend 3 - 9 mo

• 3 different antipsychotic medications from 2 different classes
• History of poor social functioning for the past 5 years
• Clozapine: Only antipsychotic to show improvement in well defined treatment resistance. 30% of pts receive benefit at 3 months. 60% of pts receive benefit at 6 -12 months

• Dystonia: muscle spasms
• Akathisia: subjective restlessness
• Pseudoparkinsonism: Akinesia, bradykinesia; Pill rolling tremor; Cogwheel rigidity; shuffling gait; masked facies
• Tardive dyskinesia: movements of the tongue, face, trunk, extremities
• Neuroleptic malignant syndrome: Tachycardia, labile blood pressure, sweating, tachypnea, incontinence, Muscle rigidity, Altered consciousness, Abnormal labs
• Cardiovascular: orthostatic hypotension
• Anticholinergic: Dry mouth, Constipation, Tachycardia, Blurred vision, Urinary retention
• Sedation
• Genitourinary: Urinary retention/hesitancy, Erectile dysfunction, Decreased libido, Ejaculation dysfunction, Priapism

• Muscle spasms: Jaw, tongue, neck
• Increases in DA release
• Hypersensitivity of DA receptors
• Onset 24 to 96 hours (50% within 2 days, 90% within 4 days)
• Risk factors: Young males, High potency agents, High doses, Previous dystonia
• Treatment: Stop offending medication, IM or IV anticholinergics or benzodiazepines, Lower dose, Start prophylactic therapy, Switch to atypical
• Prophylactic therapy: Use anticholinergics, High potency typicals, High risk patients

• Subjective restlessness
• Objective inability to be still
• DA blockade: Increase in motor activity, Dysfunction of NE
• Onset: Early, Tolerance after 4wks
• 90% of young patients
• Impulsive/violent behavior
• High risk for suicide
• All agents except clozapine
• High potency typicals, 20 to 40% of patients
• Treatment: Start at low dose, Decrease dose, Switch to an atypical agent. Anticholinergics are ineffective. Benzodiazepines/beta-blockers (Propranolol 30-120mg)

• Four cardinal symptoms: Akinesia, bradykinesia; Pill rolling tremor; Cogwheel rigidity; Shuffling gait; Masked facies
• Imbalance of DA/ACh
• Onset: 1 to 2 weeks
• Typicals: 15 to 36%
• Atypicals: Low risk, Increased risk with Risperidone > 6mg
• Treatment: Anticholinergics (Benztropine, Trihexyphenidyl, Diphenhydramine)
• Prophylaxis: Generally not needed, Controversial
• Effects: Best may be partial remission. Days to weeks. Taper 6 to 12 weeks following symptom resolution

• Buccal lingual movements: First detectable sign, Fly catchers tongue, Puckering
• Facial movements: Grimacing, Chewing
• Truncal movements: Rocking, gyrating
• Upper and lower extremities: Fast/slow, irregular, purposeless, spontaneous mvmts, Foot tapping
• Usually seen at 1 - 2 yrs
• May be irreversible
• Movements worsen under stress, attempts to suppress them and immediately following dosage decrease
• Movements improve during sleep
• Typical antipsychotics: 0.5% to 62%, 5% every year of therapy, Cumulative
• Atypicals: 0.5 – 1% at 1 yr
• Treatment: Switch to atypical
• Risperidone: 5 to 10 fold decrease versus haloperidol
• Olanzapine/quetiapine: Low treatment emergent TD rates
• Vitamin E: Mild to moderate TD. Start with antipsychotic. Require dose of 1600 IU. Benefit may take years

• Mortality 10 to 20%
• Autonomic instability: Tachycardia, labile blood pressure, sweating, tachypnea, incontinence
• Muscle rigidity
• Altered consciousness
• Abnormal labs: Temperature > 38°C, Creatine Kinase, Myoglobinuria, AST/ALT, WBC with/out left shift
• DA blockade
• Hypothalamus: Disruption of thermoregulatory process. Increase heat production due to increased muscle contraction.
• Nigrostriatal pathway: Increased rigidity and EPS
• Variable onset: Early or months/years later. 80% present in first 2 wks
• Concern: High potency typicals. Injectables

• One of the most commonly used meds for acute agitation
• Only BZ with rapid, consistent, complete IM absorption
• Benefit in agitation due to substance abuse/unknown diagnosis
• Primary agent used in the treatment of alcohol withdrawal
• Administered oral, IM, IV
• IM/IV -> onset of action within 30 min
• Duration of effect lasting 8 hrs; half-life 12-15 hrs
• Initial dose is 1-2mg q1hr; 2mg 1st dose is usually sufficient
• Other BZs: Chlordiazepoxide (Librium) and diazepam (Valium). Erratic IM absorption, active metabolites (long half-life). Midazolam -> rapid action, 1-2hr duration of effect

• One of the most commonly used meds for acute agitation
• Reduce agitation without excessive sedation or hypotension
• Treatment for underlying psychiatric disorder
• Administered oral, IM, IV
• IM/IV -> onset of action within 30 min
• Duration of effect lasting 24 hrs; half-life 12-36 hrs
• Initial dose is 5mg
• Clinical effective dosage range 10-20 mg/24hrs
• Side effects: Most common - dystonias and akathisia. Pseudoparkinsonisms, dysphoria. QTc prolongation with IV administration. Concern with lower seizure threshold (esp. in pts. w/SA)

• Haloperidol 5mg + lorazepam 2mg
• Can administer in the same syringe
• Studies -> benefit of combination superior efficacy
• Increase effect, reduced restraint use and injections
• Benefit vs. increased sedation with lorazepam
• Allows for lower doses of haloperidol
• Reduction in unwanted EPS adverse effects
• Reduction in need for anticholinergic medications

• Reduction in agitation, underlying psychopathology
• Ziprasidone: Effective w/out cardiovascular adverse outcomes. Optimal dose is 20mg
• Olanzapine: Optimal dose is 10mg; rec. 2.5-5mg in elderly pts.
• Aripiprazole: Optimal dose is 9.75mg; rec. 5.25mg in elderly pts.

• Ziprasidone: Onset 30min; half-life 4 hrs; duration 4hrs
• Olanzapine: Onset 30 min; half-life 30 hrs; duration 24hrs
• Aripiprazole: Onset 60 min; half-life 75 hrs; duration 24hrs

• DO NOT administer in same syringe with lorazepam
• Caution using olanzapine and lorazepam w/in 1hr
• Hypotension, bradycardia, syncope
• Adverse effects related to alpha-1 antagonism
• Use lower doses in pts. at risk -> dehydrated pts. on antihypertensives
• Reassess and monitor pts. prior to multiple doses

Greater sedation and hypotension w/BZ

• Are you sexually active
• Tell me your last sexual encounter
• Do you have sex with men, women or both
• Is there any violence in your relationship or in your family
• Can you meet with friends
• Can you make decisions about your life without your partner checking in on you
• Is there a loving no – in your sex life?
• What happens when you say no to your partner when she/he wants sex?
• Tell me about your current relationship – how do you spend time together – do you feel liked – understood – do you like and understand your partner
• What do you use for protection from pregnancy – or disease
• Has anyone in your family ever touched you inappropriately
• Have you ever had an STD
• Have you ever had a child, how many
• Have you ever had a miscarriage or abortion
• Have you ever had an abnormal pap

• Have you decreased stream with urination (hints at prostrate)
• Any hesitancy with urination
• Any erection difficulties
• Are you enjoying sex
• Are there times when there is a difference in desire – you want to be sexual your partner does not – how do you deal with that
• Do you and your partner know how to please each other?

• Have you ever had an orgasm
• What happens when you are alone – can you orgasm – if yes, the issue is not biological it is relational – if no it may be she does not know her anatomy
• Many women do not know their own anatomy – draw it for them – tell them of the clitoris
• Is there a difference in frequency of desire between you and your partner – how do you deal with that
• Do you know what pleases you and how to speak about that

Men erection, scrotum thickens; Women lubrication, clitoris lengthens

• Men penis engorges, testes enlarges, right testicle rises and rotates then left testicle rises and rotates, prostrates contracts
• Women clitoris retracts under hood, inner part of vagina expands, outer part of vagina thickens and contracts forms orgasmic platform
• Both men and women skin flush, heart race increases, blood pressures rises, muscle tense

• Men penis contracts, ejaculation
• Women – vagina and uterus contract
• Mild 3 to 5 contractions intense 8 to 12
• Shortest phase, most intense, most internal
• Total body rectal sphincter contracts, heart rate and blood pressure increase, facial muscles spasm, foot spasms, gasping

• Men penis becomes flaccid, scrotum thins and drops, testes descends, body relaxes
• Women clitoris, inner and outer lips return to normal, cervix opens slightly and drops, uterus drops, vagina collapses and thins, body relaxes

• Excitement stage of sexual activity is associated with sexual objects or orientations different from those usually associated with adult sexual stimulation (ex: the stimulus may be a woman’s shoe, a child, animals, instruments of torture or incidents of aggression)
• Usually has early psychological roots
• Poor experiences with sexual activity frequently reinforce this pattern over time
• Exhibitionism: Impulsive behavior of exposing genitalia to unsuspecting strangers in order to achieve sexual excitation. Childhood sexual behavior carried over into adult life
• Transvestism: Recurrent cross-dressing behavior in a heterosexual man for the purpose of sexual excitation. Such fetishistic behavior can be part of masturbation foreplay
• Voyeurism: Involves the achievement of sexual arousal by watching the activities of an unsuspecting person, usually in various stages of undress or sexual activity. In both exhibitionism and voyeurism, excitation leads to masturbation as a replacement for sexual activity.
• Pedophilia: The use of a child of either sex to achieve sexual arousal, and in many cases, gratification. Contact is frequently oral, but can also include intercourse. More commonly men. Pedophiles usually have difficulty in adult sexual relationships and men who perform this act are frequently impotent.
• Incest: Involves a sexual relationship with a person in the immediate family, most likely a child. In many ways similar to pedophilia (intrafamilial pedophilia).
• Sexual Sadism: Attainment of sexual arousal by inflicting pain upon the sexual object
• Sexual Masochism: Achievement of erotic pleasure by being humiliated, enslaved, physically bound, and restrained. May be life-threatening, since neck binding or partial asphyxiation usually forms part of the ritual. Much more common in men

• Erectile dysfunction: Inability to achieve or maintain an erection firm enough for satisfactory intercourse. Sometimes patients use the term to describe premature ejaculation. If patients still get nocturnal erections, the dysfunction is most likely psychological in origin. Psychological ED is caused by interpersonal or intrapsychic factors (marital dysharmony, depression).
• Ejaculation disturbances: Include premature ejaculation, inability to ejaculate, and retrograde ejaculation. Pathogenic factors are those that interfere with learning control, most frequently sexual ignorance. Intrapsychic factors (anxiety, guilt, depression) and interpersonal maladaptation (marital problems, unresponsiveness of mate, power struggles) are also common. Organic causes include interference with sympathetic nerve distribution (due to surgery or trauma) and the effects of pharmacologic agents (SSRIs or sympatholytics)

• Vaginismus: Conditioned response in which a spasm of the perineal muscles occurs if there is any stimulation of the area. Desire to avoid penetration. Sexual responsiveness and vasocongestion may be present, and orgasm can result from clitoral stimulation
• Frigidity: Complex condition in which there is a general lack of sexual responsiveness. The woman has difficulty in experiencing erotic sensation and does not have vasocongestive response. Sexual activity varies from an active avoidance of sex to occasional orgasm. Causes include poor sexual techniques. Early traumatic sexual experiences, interpersonal disharmony (marital struggles, use of sex as means of control) and intrapsychic problems (anxiety, fear, guilt). Organic causes include anything that might cause pain in intercourse, pelvic pathology, mechanical obstruction, and neurologic deficits
• Disorders of sexual desire: Diminished or absent libido in either sex and may be a function of organic or psychological difficulties (anxiety, phobic avoidance). Any chronic illness can reduce desire. Hormonal disorders and CKD contribute to deterioration in sexual desire. Menopause, alcohol, sedatives, opioids, marijuana, and some medications may affect sexual drive and performance

Gender dysphoria is a development of a sexual identity that is the opposite of their biologic one

• Attempt to deny and reverse biologic sex by maintaining sexual identity with the opposite gender; do not alternate between gender roles; they assume fixed roles of attitudes, feelings, fantasies, and choices consonant with those of the opposite sex, all of which clearly date back to early development
• Male to female transsexuals in early childhood behave, talk, and fantasize as if they were girls. They do not grow out of feminine patterns; they do not work in professions traditionally considered to be masculine; they have no interest in their own penises; they desire for sex change early and may culminate in a female lifestyle (hormone treatment and surgical procedures).

• Men: erectile dysfunction. Check for cardio vascular, diabetes, depression, meds
• Women – low desire, lack of libido. Check for cardiovascular, diabetes, hysterectomy, hormones – lack of lubrication
• Most sexual issues are relational – the mind is an important sex organ
• How people relate can promote or prevent intimacy

• Psychological: psychotherapy; frequently focus on barriers to normal arousal response; the expectation in that variant behavior will decrease as normal behavior increases
• Behavioral: Aversive and operant conditioning techniques are only occasionally successful; in some cases, sexual arousal disorders improve with modeling, role-playing, and conditioning procedures; emotive imagery is occasionally helpful in lessening anxiety in fetish problems
• Social: Self-help groups has facilitated adjustment to an often hostile society; attention to the family is particularly important
• Medical: Medroxyprogesterone acetate (a suppressor of libidinal drive) is used to mute disruptive sexual behavior in men of all ages, onset of action generally 3 weeks, usually reversible; Fluoxetine and other SSRIs in depression doses may reduce some of the compulsive sexual behaviors including the paraphilias; transsexuals treated by genital reconstructive surgery

• Medical: identification of reversible cause is most important; PDE-5 inhibitors used to treat ED; avoid meds that cause ED
• Behavioral: syndromes resulting from conditioned responses have been treated with conditioning techniques; vaginismus responds well to desensitization with graduated Hegar dilators along with relaxation techniques
• Psychological: psychotherapy; combined behavioral-psychological approach usually produces results most quickly
• Social: Proximity of other people in a household is frequently an inhibiting factor in sexual relationships – social engineering may alleviate the problem

A severe breakdown of mental functioning with impaired contact with reality

• Process and content
• Thought disorder
• Tangentiality
• Loosening of associations
• Poverty of thought
• Thought blocking

• Abnormal speech
• Poverty of speech
• Mutism
• Echolalia
• Neologisms
• Clang associations
• Verbigeration

Perceptual disturbances: illusions, hallucinations, delusions

• Auditory – typical of schizophrenia
• Visual – suggests ‘organic’ etiology
• Tactile – suggests ‘organic’ etiology
• Olfactory – assoc. w/ temporal lobe pathology
• Gustatory

• Fixed, bizarre, unrealistic beliefs.
• Not subject to rational argument.
• Not accounted for by accepted cultural or religious beliefs.
• Patient may conceal.

• Paranoid: Paranoia covers a broad range. General mistrust or suspiciousness. Plausible but false beliefs. Bizarre delusions. Elaborate delusional systems
• Grandiose
• Religious
• Nihilistic
• Somatic

• Thought insertion
• Thought withdrawal
• Thought broadcasting
• Ability to read others’ thoughts
• Ideas of reference

• Abnormalities of behavior
• Stereotypies or “automatisms”
• Catatonia

• Abnormalities of affect
• Blunted or flat
• Bizarre
• Incongruent with content

• Alcohol intoxication or withdrawal
• Cocaine/amphetamine intoxication
• Benzodiazepine withdrawal
• Hallucinogens
• Phencyclidine
• Steroids
• Anticholinergics

• Encephalitis (e.g., herpes simplex virus)
• CNS lupus
• Brain tumor
• Porphyria
• Complex partial status epilepticus
• Component of delirium of various etiologies.
• Always assess sensorium, orientation.
• First episode deserves thorough neurological work-up

• Major depression with psychotic features may include delusions (eg, “I am dying”) and hallucinations (eg, “Kill yourself.”).
• Psychotic features may be mood-congruent or mood-incongruent.
• Acute mania (in bipolar disorder) may involve all types of psychotic features. Acute episodes of manic psychosis and schizophrenia may appear identical.

• At the border between mood disorder and schizophrenia.
• Psychotic symptoms occur during major mood episodes (depression or mania) AND PERSIST during extended periods outside of the mood episodes.

• Flashbacks (vivid re-experiencing of traumatic event while awake) may include hallucinations (seeing, hearing, smelling, feeling the event).
• Hypervigilance may resemble paranoia, though does not involve organized delusions.

• Psychosis and personality disorders
• Cluster A: Schizoid, Schizotypal, Paranoid
• Cluster B: Borderline

• ALWAYS assess cognitive function (orientation, memory, calculation, speech) in evaluation of psychosis.
• Disorientation and memory impairment strongly suggest delirium.
• Delirium may involve all types of psychotic features.
• Tactile and visual hallucinations are suggestive.

• Paranoid delusions : “Someone is stealing from me.” 10-20%. May decrease over time.
• Misidentification delusions: “You’re not my daughter. You’re an imposter.” 10-20%. Modest increase over time.
• Hallucinations, 10-20%. Stable over time.

• Visual hallucinations are 1 of the 3 core features of Lewy-Body Dementia.
• Psychosis is not so prominent in other forms of dementia.

• Lasts at least 1 day, but less than 1 month.
• Often in response to severe stressor.
• More common in people with personality disorder and limited coping abilities.
• Followed by full return to premorbid functioning.

• Non-bizarre delusions (jealous, erotomanic, somatic, persecutory, grandiose)
• Limited overall impairment.
• Behavior is not obviously odd or bizarre.
• May have hallucinations directly related to the delusion.
• Must never have met criteria for schizophrenia

• Features similar to schizophrenia, but duration less than 6 months.
• Most of these patients will go on to fulfill criteria for schizophrenia diagnosis.

• Hallucinations
• Delusions
• Disorganized speech and behavior
• Agitation
• Respond fairly well to conventional antipsychotic medications.

• Avolition
• Withdrawal/autism
• Anhedonia
• Blunted affect
• Poverty of speech
• May respond somewhat better to ‘atypical’ antipsychotic medications.

• Hospitalize if suicidal, homicidal, severely agitated or disorganized, or acutely psychotic.
• Educate patient and family about the illness, treatment.
• National Alliance on Mental Illness (NAMI)
• Supportive psychotherapy promotes acceptance of illness, setting realistic goals, medication compliance.
• Coping skills and “life skills” training to reduce, manage stress and enhance function in society.
• Support abstinence from alcohol, drugs.
• Reduce exposure to “expressed emotion”.
• Vocational rehabilitation
• Clubhouse model for support, structure.
• “Assertive community treatment” model
• Financial planning, guardianship of funds.
• “Recovery model” emphasizes patient’s goals, partnership between patient and clinicians.