A Short Course in Psychiatry

James Morrison, M. D. Professor of Clinical Psychiatry Oregon Health & Science University

January 2009

Contents

Preface Chapter 1 Chapter 2 Chapter 3 Chapter 4 Chapter 5 Chapter 6 Interviewing Psychiatric Patients Making a Psychiatric Diagnosis Depression Mania and Mood Swings Psychosis and Schizophrenia Anxiety and Panic

iii 1 29 33 54 69 90

Preface
Remembering my own years in training, I had originally thought to call this collection The Impoverished Students Guide to Psychiatry. Whatever you choose to call it, this copyrighted material is being provided free to OHSU students, residents, trainees and faculty. You may download it to your computer or PDA and print out portions for your personal use. I would prefer that it not be disseminated outside our academic community. For those who prefer an actual book (or an indexsorry about that, but time got away from me), Id recommend Introductory Textbook of Psychiatry, by Nancy C. Andreasen and Donald W. Black. It has been the standard text used at OHSU for several years; copies are in our library. I want to acknowledge the faithful, close reading of this material by James Boehnlein, MD, whose many suggestions I deeply appreciate. However, any errors youll find are my own responsibility. This is a work in progress; Id greatly appreciate it if youd write to me about this material what do you find useful, whats confusing, how can we improve it for readers in years to come? James Morrison, M. D. Portland, Oregon January, 2009 morrjame@ohsu.edu

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Chapter 1

Interviewing Psychiatric Patients

The patient interview provides the gateway to the health of the patient. Because it is both a science and an art, the skill of interviewing will improve as you continue your training. Although psychiatric patients differ in some ways from medical and surgical patients, what you read here will apply to nearly every patient you meet.

Getting Started
When I was in training, students bore the honorific title of Doctor, but everyone, including the patients, knew it was a fraud. Much better to introduce yourself, Im Pat Marshall, a medical student. Ask if the patient is agreeable to the interview, and point out how long you expect it will take. Also mention that youll probably take some notes. During introductions, show the patient where to sit. Try to sit across the corner of a desk or table from the patientthis gives you room to change the distance between you, as indicated by the patients need for space and comfort. (Across the full width of a desk erects a barrier and hinders flexibility.) Start off with a brief question that shows where youd like to go. What caused you to come for this evaluation? works for outpatients; the inpatient equivalent is, Why were you admitted to the hospital? Some clinicians like to begin with small talk, but psychiatric patients often feel too troubled to care much about ball games, traffic jams, or the weather. Note that the two questions Ive quoted are open-ended. That means, they cant be answered yes or no and you havent suggested a multiple-choice answer. Open-ended questions help you establish a working relationship with your patient: They give the patient the greatest possible latitude in coming up with a response, so you dont limited the scope of your information. They serve as bait when you are fishing for the sorts of problem youll need to explore. Because the patient does most of the talking, they allow you to assess your patients thought and speech patterns. Patients who are encouraged to talk freely tend to like the person doing the encouraging. 1

Interviewing

Free speech
Your open-ended invitation just to talk about the reasons for the evaluation should usher in a few moments of what I call free speech, when your patient can rattle on about whatever comes to mind. Most patients will respond with a few sentences, and then youll have to prompt for more information with more open-ended invitations, such as: Tell me more about that or And then what? Sometimes, just a nonverbal signal such as nodding your head or smiling can indicate that the patient is on the right track and youd like to hear more. During free speech, you should be looking for hints that your patient has a problem in one or more of these areas: Mood disorders (abnormally high or low mood) include such symptoms as affect that is depressed or flat (or too high and bubbly), loss of interest in usual activities, reduced (or increased) activity level, changes in appetite or sleep patterns, crying, speech that is slowed or speeded up, feeling worthless, and death wishes or thoughts of suicide. Anxiety disorders can be indicated by complaints of nervousness, excessive worry, panic, unreasonable fears, obsessional thinking or compulsive behavior, a history of severe emotional or physical trauma, physical complaints such as palpitations of the heart or irregular heartbeat, sweating, trembling, trouble breathing, and dizziness. Psychosis may be suggested by delusions, hallucinations in any of the senses, bizarre behavior, speech that is incoherent or hard to follow, flat or inappropriate affect, fantasies or illogical ideas, social withdrawal, and impaired insight or judgment. Difficulty thinking (cognitive disorders) includes defects of memory, delusions, hallucinations, fluctuating affect, bizarre or unpredictable behavior, and poor judgment. Physical complaints can be signaled by increased or decreased appetite or weight, convulsions, headache, weakness, neurological complaints, and pain that can occur in one or more of many locations throughout the body. Also watch for a medical or mental history that is vague or complicated, a history of sexual abuse, and repeated treatment failures. Social or personality problems may be suggested by repeated marital conflicts, legal difficulties, peculiar or bizarre behavior, a presentation that is overly dramatic or ingratiating (or grumpy), or by job problems: being fired, demoted, repeatedly tardy. Substance misuse includes indicators such as use of more alcohol than two drinks a day, financial or legal problems, health consequences of use (cirrhosis, blackouts, abdominal pain, vomiting) and social consequences such as fights, marital problems, and loss of friends. Each of these areas comprises a variety of disorders that have symptoms in common. Later on, youll gather details about each area your patient mentions. After moments to minutes of letting your patient talk freely, youll sense that youve obtained a broad outline of whats uppermost in your patients mind. Then, after asking, Are there any other important problems we havent mentioned? move on to explore in depth the problem areas youve identified.

Rapport
Before we move on, lets consider the relationship youre trying to establish. Rapport, the sense of mutual trust and understanding that helps people work together, is the second of two basic

Interviewing

goals you hope to score during your initial interview (clinical information is the first). Most patients will expect to like you, but dont coast on this expectation; take steps to build good will: Watch your patients demeanor. If its depressed, you will naturally feel like moving a little closer for support. If angry or hostile (or euphoric), youll want to back off to give each of you more personal space. (Heres where your seating arrangements shines.) Monitor your own demeanor. Maintain eye contact and nod your head to show that you are listening. Patients who perceive that you like and respect them will return the favor. Speak plainly (professional jargon can be really confusing) and with compassion. You may be tempted to say, I know how you feel but try not to. Unless youve suffered the loss of a loved one, been divorced, or experienced the countless disasters that patients bring, your words can come across as hollow. You might do better to express interest and compassion: Ive never experienced [that situation], so I can only imagine how horrible you feel. I can see that it upset you terribly. You must have felt miserable. If ethnicity or regional dialect makes it hard to understand your patients speech, remember that the patient may find you hard to follow, too. Acknowledge that you have different accents and point out that either of you may have to ask for a repetition at times. Follow up on material that is obviously important to the patient. That may seem hard to do early in training, when just thinking up the next question is an effort. But if instead you strive for a relaxed conversation that wont yield everything you want to know, both of you may have a more productive experience. You can always return to the patient later for details that you overlooked the first time. Of course, your own feelings can heavily influence rapport. Try to understand any objectionable behavior or attitudes in terms of the psychological problems you are evaluating. If you focus on the patients feelings, rather than words or behavior, you might avert your own negative feelings. For example: PATIENT: I dont care about women. Id like to see every one of them burn in hell. INTERVIEWER: Sounds like youre awfully angry. Have you had some bad experiences? PATIENT: Well, let me tell you. You got a few hours? This patient then went on to talk about his overbearing mother and how each of his two wives had abandoned him. On the positive side, you can offer praise when your patient does something especially well. Almost anything will do: Youve really given me a good overview of your problem. I think we can move on to some other information, now. Thats about the best serial sevens Ive heard this week! When you do offer praise for performance, make sure that it is both accurate and heartfelt. Psychiatric patients are often keen at detecting BS, and if you are insincere, it can not only poison your interview but imperil your chances at a solid future relationship.

Interviewing

Boundaries
The doctorpatient relationship has changed since I was a student. Then, the doctor was often an authoritarian lawgiver who decided for the patient; now, most of us prefer the less formal role of collaborators who explore issues with the patient. The latter style is more comfortable and it encourages patients to participate in treatment decisions. It puts two minds to work, rather than loading all the responsibility onto the clinician. Patients who contribute to the management plan adhere better to treatment and complain less about bumps in the road to improvement. Yet, even clinicians who encourage friendly collaboration must maintain boundaries. I find I can maximize personal dignity and better maintain distance by using a patients title and last nameMiss, Mrs., Ms., Mr. Jackson. I realize that this is not the universal practice among clinicians, but it can serve us all well: it is unseemly any ward personnel, but especially students, to address patients by their first names or infantilizing terms. A recent study found that when older patients are addressed in what has come to be called elderspeakSweetie, Dear, How are we today, Hon?they respond with greater depression and dependence, less selfesteem and cooperation. Many elderly people hate to be called Young Lady (or Young Sir), which can seem mocking and insincere. The first step in maintaining boundaries is to know where they are. The overarching principle is to focus on the patients interests and needs, not on your own. Its generally safest not to reveal too much about yourself to your patients, especially during the initial interview. A resident confided to his new patient that he was a reserve peace officer. He later discovered that the patient had a severe personality disorder and hated the police. With this caveat in mind, sometimes you can encourage cooperation by identifying something that you and the patient share. If you attended the same high school, that coincidence might nudge you in the direction of rapport. However, to avoid excessive familiarity, use this technique sparingly, seldom more than once with a given patient. And Id scrupulously avoid extending it to politics or religioneven offhand remarks have a way of getting around, and you never know when someone else will be put off by an opinion that your current patient applauds. Of course, you dont have to answer personal questions, but you may want to do so; it depends on the patients reason for asking it may be simple curiosity or a desire to obtain reassurance about the clinicians competence: PATIENT: Were you reared in this city? INTERVIEWER: What makes you ask? PATIENT: My mother told me to be sure to get a therapist who grew up here. She says no one else could really understand what it was like, growing up in a ghetto, and all. INTERVIEWER: I see. Actually, I didnt grow up here, but I got most of my training here. Ive lived in town for nearly 8 years, so I have a pretty good idea of what some of your experiences must have been. But I have the feeling youll be able to tell me a lot more. A question students hear has to do with age: You seem so young for this kind of work how old are you? One way to handle personal questions, or any question, for that matter, is to counter with one of your own: Why do you ask? It plays for time and information that may help you decide whether to answer the question directly. (I wouldnt give a direct answer about age, which really isnt any of the patients business; instead, Id probably thank the patient for

Interviewing the compliment and with a big smile say something like, People tell me I look young for my age or, My actual age might surprise you. But lets get back to my question, which was

Managing the Early Part of Your Interview

During the early part of your interview, you want to keep your patient talking with as little intrusion as possible. Several non-directive techniques (they urge further speech without dictating its content) can facilitate this goal: Nonverbal encouragements. Experienced interviewers instinctively use several subtle, nearly invisible methods: they maintain nearly continuous eye contact, smile or nod for appropriate responses, and lean in a little closer to show interest. (Barely) verbal encouragements. Sometimes, just a syllable or twoYes or Mmhmmcan indicate that you understand and that the patient should just keep talking. Perhaps the most straightforward encouragement is a simple, direct request, such as Please explain what you mean or Tell me more about that. Repeat your patients own last word to request more in the same line of thought. PATIENT: and during the last few weeks, Ive thought a lot about death. INTERVIEWER: Death? PATIENT: Well, Dad died, and I felt so frightened. Ive got so much living to do Reach back to a phrase or idea that wasnt the patients last-spoken thought: Earlier, you said that youd thought a lot about death. What did you have in mind? Just re-request the information. INTERVIEWER: Can you tell me about your drinking? PATIENT: Now, my dad, he was a heavy drinker! INTERVIEWER: Yes, and how about your drinking? From time to time, briefly summarize whats been said, just to make sure you and your patient are on the same page. So, as I understand it, you were doing pretty well until 8 or 10 months ago, when you lost your job, your wife left, and then you started drinking. Is that right?

Offering reassurance
Reassurance is whatever you do to increase your patients confidence or sense of well-being; it also promotes rapport. Smiles and nods are fine, but mostly, we reassure by what we say. To be truly supportive, reassurance must be sincere, factual, and specific to the situation. If used too often, it can seem forced or false. You must avoid false generalizations based on insufficient knowledge, such as I wouldnt worry about that or Im sure it will all work out just fine. (Many patients will grumble that, in your place, they wouldnt worry, either.) And because you obviously cant peer into the future, your words will seem hollow and reduce your credibility. You can reassure with praise, but only offer it when its deserved: I think you handled your boss with tact and sensitivity. I can see why you are valued in your company.

Interviewing

Gathering the Database

History of the present illness
Once youve identified some of the major problem areas you need to explore, start exploring! This means learning all you can about the current episode of illnesshow it began, its symptoms, consequences, and possible stressors. All the while, you need to watch for hints of new territory that you also will need to cover. Learn as much as possible about your patients symptoms. Are they constant or do they come and go? If episodic, how often do they occur and with what intensity? Has the intensity or frequency changed recently? Are the symptoms associated with any factor such as time of day or type of activity? For example, you can characterize auditory hallucinations as to their content (noises, mumbled speech, isolated words, complete sentences), location (inside the patients head, in the air, outside the room), and intensity (distant whispers to loud screams). Vegetative symptoms Vegetative symptoms, an ancient term that refers to body functions involved with preserving health and vigor, are common; always look for evidence of change from prior functioning in: Sleep. Many patients complain of insomnia. Learn where in the sleep period it typically occursterminal (or late, usually associated with severe depression or melancholia); interval, in which patients awaken during the night (especially found in heavy drinkers and those who have PTSD); early (experienced from time to time by normal adults who have problems of living). Some patients sleep too much when they are ill (especially true of depression in younger people). Appetite and weight. Was weight change intentional? If your patient hasnt weighed recently, try to judge by how closely clothing seems to fit. Classically, appetite and weight decrease with severe depression, but they increase even in some patients with mood disorder. Energy level. Is constant fatigue a change? Has it interfered with normal activities? Daily mood variation. How people feel can vary with time of day. Some depressed patients feel worse upon arising but improve throughout the day; others experience the opposite pattern. Sexual interest and performance. Interest in sex is often an early casualty of mental disorder, so explore whether your patients frequency, ability, and enjoyment of sex have changed. For most mental disorders, the direction will be down; for mania, libido may increase. Onset and sequence of symptoms Your patient may be able to tell you exactly when the symptoms began: I started to feel depressed when my wife said she was leaving. More usually, symptoms begin gradually or the patient is vague about onset. Try to encourage precision: Had you started to feel depressed by your birthday this year? By Christmas? If this approach draws a blank, you might ask, When did you last felt well? If even this fails, explore the sequence in which your patients problems began: Which started first, the depression or the renewal of your drinking? The answer could help determine the type of treatment you eventually recommend.

Interviewing Stressors

Some disorders seem to begin spontaneously, but youll often identify an event that may have caused, precipitated, or worsened your patients mental problems. From a vast range, you must judge which alleged stressors are valid. (For example, a patient claimed his depression started when he discovered fleas on his dog.) If you havent heard about any possible stressors, ask: Was something going on that might have started your symptoms? Possibilities include issues at work, at home, with spouse or friends, legal problems, illnesses, and anniversary reactions. Try to learn why your patient appears for evaluation now. Sometimes its obviousacute intoxication or a suicide attemptbut an outpatient may have come in at the behest of concerned relatives, in fear of job loss, or out of concern about worsening symptoms. Consequences of illness The effect of mental disorder on human interactions can help you judge its severity; sometimes (as with antisocial personality and substance use disorders) it can even determine the diagnosis. Youll therefore want to learn what the effect of symptoms has been in these areas: Marital and love relationships. Has there been serious discord, even separation or divorce? Interpersonal. Has the patient avoided or fought with friends, been shunned by relatives? Legal. Ask: Have you ever had any police or legal difficulties? Follow up positive answers with Have you ever been arrested? How many times? Have you been in jail? For a total of how long? And of course, What were the charges? Employment. Has your patient missed work, quit a job, or been fired as a result of illness? Disability compensation. Chronic illness may trigger benefits from the Social Security Administration, Department of Veterans Affairs, state compensation board, or private insurance. Personal interests. Seriously ill patients typically lose interest in sex, hobbies, reading, TV. Previous episodes Youll need to learn details of prior episodes: When did they occur? What were the symptoms? The diagnosis? What were the social consequences? If hospitalized, how many times and for how long? What treatments were tried? Which worked best? Was recovery complete? For how long? Was there a period of time that the patient remained well without prophylactic treatment? For previous medications, besides such basic information as name, dose, frequency, duration of use, and effects (both wanted and unwanted), learn how well the patient cooperated with treatment. People often resist admitting to poor compliance, so ask: Have you ever had trouble following your doctors advice? What sort of difficulty have you had? Suicide and other violent behaviors Every patient requires an evaluation of suicide potential. Some beginning interviewers worry that theyll suggest suicide to a patient, but anyone with a potential for self-harm will have already considered it; the real risk is in asking too late. You can gently approach the issue: Have you ever had desperate thoughts, such as wanting to be dead? Pursue positive replies with questions about thoughts of self-harm, plans, and past suicide attempts. (Beware a no answer attended by hesitation, shifting gaze, or tearseach suggests that the answer may be less than candid.) You could comment, You seem so uncomfortable, I hate to pursue this subject, but I feel I must.

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Facts about past suicide attempts help predict further attempts. You must assess both the physical and psychological seriousness of any previous attempt. A physically serious attempt is one that could result in significant bodily harm, such as swallowing a potentially lethal drug dose, severing an artery or large vein, inducing a deep coma, or inflicting a gunshot wound to the abdomen. At the other extreme are attempts that suggest the patient had something in mind other than dyinggestures such as a lightly scratched wrist or swallowing 4 or 5 aspirin. A psychologically serious attempt is one where death seems clearly intendedthe patient took pains to avoid discovery or greets survival with regret: Im sorry it didnt work or Ill try again. Psychologically less serious attempts are those that are made impulsively, perhaps when someone else was with the patient, or when the patient admits, Im glad I didnt succeed. Respond to suicide behavior that is either physically or psychologically serious with speed and vigor. Avoiding suicide and other harm is a duty of clinicians, but so is maintaining confidences. If you perceive any danger to or from your patient, immediately notify your supervisor. At another time, youll explore the legal aspects of medicine in Oregon. Explore any risk of violence. A history of domestic quarrels or legal difficulties can ease you in to this line of questioning. Otherwise, youll need to ask whether the patient has ever been involved in fights, harmed others, or been concerned about controlling impulses. All health care personnel must ensure their own personal safety when talking with patientsbeing the target of a threat or assault is worse than no fun, trust me. So: 1. Provide an unobstructed exit from your interview room (two doors, or put yourself closer to the door than is the patient). 2. The room should have an alarm or someone should be within earshot of a call for help. 3. Be especially wary of any patient who has a history of violence or who should be taking antipsychotic medication, but isnt. 4. Watch for indicators of potential violence in the patients voice (rising tempo or pitch), words (threats or insults), and body language (agitation, clenched fists). 5. If you sense danger, announce that you are leaving the room (the announcement is to avoid startling the patient), then do so. 6. Then, get help at once. Substance misuse Substance misuse is so common (about 8% of adult Americans, 25% of adults with psychiatric illness) that you must always consider it, even in teens and senior citizens. To normalize drinking of alcohol, thereby reducing the patients impulse to conceal it, assume that everyone drinks some and ask: In an average month, on how many days do you have at least one drink of alcohol? Then ask On a typical drinking day, how many drinks do you have? I worry about anyone who consumes more than 60 drinks per month. (The following drinks have roughly the same alcohol content: a 12-ounce beer, a 6-ounce glass of wine and a 1-ounce shot of 80-proof hard liquor.) Dont be put off by someone who says, I dont touch alcohol. That could mean, I havent had a drink since Saturday night. Although the amount a person drinks is an important indicator, alcohol dependence, which we used to call alcoholism, is defined by its consequences. For alcohol or drug use, youll need to explore the following areas:

Interviewing Loss of control. Drinking more than the patient intends, setting rules about when to drink, gulping drinks, being unable to stop after the first drink Medical. Liver trouble, vomiting spells, blackouts (amnesia for events while drinking) Legal. Arrests, drunk driving, accidents Interpersonal. Loss of friends, divorce, fighting, guilt feelings Financial. Spending money on drink/drugs that should have gone to food or family support Job. Absenteeism, being fired Follow up positive responses with: Have you ever been concerned about your [drinking, drug use]? Were you ever treated for the use of [alcohol, drugs]? What happened as a result of treatment? Whats your longest period of [sobriety, being clean]? How did you achieve it?

Getting the Facts About the Present Illness

An accurate diagnosis requires all the relevant information. Sometimes you must explicitly state that you need the truth. (Some patients, especially teenagers, dont realize that misinformation can have serious consequences.) Thats why I might say, I understand that you hesitate to confide in me. Lets play it this way: If you feel you cant tell me the truth, just say, Lets skip that for now, and well move on. That way, I wont get the wrong idea about you. Studies show that open-ended questions are more likely to yield valid information, so continue to use them when you can. For example, Instead of Did you have insomnia with your depression? try, How was your sleep then? (Some depressed patients sleep too much.) Instead of How often have you been hospitalized? say, Please tell me about your other hospitalizations. (You might learn about drinking episodes or suicide attempts.) Instead of Did your appetite change? ask, To what extent did your appetite change? (To what extent can change nearly any closed-ended question into an open-ended one.) Each symptom has its unique set of details that must be explored, but for a full, rich exploration of any behavior or event, certain items of information are always necessary. They include accurate details about these aspects of your patients symptoms: Type Duration Severity Context in which they occur Frequency This exploration will require the use both of closed-ended and open-ended questions: INTERVIEWER: When did you first notice these episodes of anxiety? [Closed-ended] PATIENT: It must have been about 2 months agoI had just started my new job. INTERVIEWER: Please describe an episode for me? [Open-ended] PATIENT: For no reason, I start to feel nervous. Then I cant breathe. Its awfully scary. INTERVIEWER: How often have these attacks occurred? [Closed-ended] PATIENT: Im not sureits been getting more frequent.

Interviewing INTERVIEWER: Several times a day, once a week? [Closed-ended, multiple-choice] PATIENT: About once or twice a day now, I suppose. INTERVIEWER: What do you do about it? [Open-ended]

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PATIENT: Im too shaky to stand, so I just sit down. In 15 minutes or so, it starts to go away. INTERVIEWER: What sort of help have you sought before? [Open-ended] A few rules For the sake of completeness, Ill mention a few other obvious rules of interviewing: Use language the patient understands. Sleeping with for having sex is commonplace; other terms may not be, so you might have to use your patients street terms for sexual acts and body functions. Dont phrase questions in the negativeit telegraphs the expected answer. You havent been drinking heavily, have you? essentially demands the answer, Heck, no. Avoid leading questions. Like negative questions, leading questions hint at the answer expected; judges on TV crime shows overrule them, and so should you. Instead of Has drinking ever caused serious problems, such as missing work? ask Have you ever missed work because of drinking? Avoid double questions. (Have you had trouble with your sleep or appetite?) They may seem efficient, but double questions are often confusing. Too, the patient may respond to one part of the question and ignore the other, without your realizing it. Encourage precision. Where appropriate, ask for dates, times, and numbers. Keep questions brief. Long questions with involved explanatory detail can confuse the patient; they also occupy time you could be using to listen to the patient.

Confrontations Confrontation doesnt imply angry. It means that something needs clarification, perhaps a historical inconsistency or a contradiction between the story and how your patient seems to feel. However, try to avoid even friendly confrontations in an initial interview, when you dont really know the patient well. But when the stakes are highlets say your diagnosis turns on this factyou must clear up the confusion with a confrontation. Then, use a gentle, supportive manner. Help me understand: You just said that your father threw you out of the house, but earlier I thought you said he died years ago. The I thought draws the sting of any implied criticism by suggesting that you might be the one who is mistaken. Heres another way to soften the question: When you told me what happened to your wife, I felt sadbut you are smiling. What else is there to this story? Of course, during an interview session, you should play the confrontation card sparingly.

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Interviewing about feelings

Studies show that beginning interviewers often neglect to ask about feelingsa serious omission in a mental health interview. Eliciting quality information about feelings is usually pretty easy just ask, using techniques weve already discussed: direct requests and open-ended questions. When using a direct request, be sure to mention feelings or emotions specifically. For example, if you ask, What do you think? you might obtain only cognitive material. Instead: How did learning about your husbands affair make you feel? or What was your state of mind when you found out youd been demoted at work? Open-ended questions allow the scope to sort out possibly ambivalent feelings. A person who talks at greater length is more likely to reveal true emotions. For example, INTERVIEWER: You said youd considered leaving your jobtell me more about that. PATIENT: Ive had a really tough time at work, what with downsizing. My boss has put me under an awful lot of stress. At times Ive felt that I cant even do my job INTERVIEWER: (Nods without speaking) PATIENT: But my husband points out, I could spend more time with the kids, and we could get along on less money. And I could try writing the novel Ive dreamed about Although most patients will give you information about any emotional state you are interested in, some find it hard to talk about feelingsperhaps their relatives hid their emotions or their culture discouraged behavior that isnt macho. Some just dont recognize their own feelings or have difficulty connecting them to their experiences (a condition called alexithymia); others may understand very well how they feel, but resist exposing their vulnerabilities. Here are some other techniques for eliciting emotions: Express sympathy or concern. Anyone whos had your problem would feel hurt [or angry or sad]. Reflection of feelings. This means, you state the emotions you think the patient might feel in a particular situation. Your boss gave his nephew the promotion you thought you had coming? You must have been livid! And depressed. Picking up on emotional cues. You provide a verbal expression of the slight (often nonverbal) cues to emotional states. When you mentioned your daughter just now, I thought you looked a bit down. What were you feeling? Analogy. For a patient who cannot identify feelings, try to evoke the context of a previous experience. Did you feel that way when your father died? And always, probe for more details. About those episodes of intense anxietycan you tell me some more about them? Then, keep probing until you have all the facts.

Handling the excessively emotional patient Emotions sometimes interfere with communication, as with people who dont understand the cause of their own feelings, for those who were reared in families where intense expression of emotion was the custom, for very anxious or depressed people, and for those who control others through intimidation. These techniques can help cap excessive verbal and behavioral output:

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Label the emotion. Just saying, You really feel angry about this. Angry and frustrated! conveys your understanding, which may allow the patient to turn down the heat. Speak quietly yourself. If your patient shouts, lower the volume of your own voice. Most people find it hard to yell at someone whom they must strain to hear. Re-explain what you want. I know your ex-wife infuriates you, and perhaps later we can discuss that some more. Right now, I need to learn about your current relationship. Switch to close-ended questions. INTERVIEWER: Can you tell me about your previous marriage? PATIENT: It was god-awful! That bitch should rot in hell. She wouldnt even let me INTERVIEWER (interrupting): Did you and she have any kids? PATIENT: Two, and theyre just as bad as their mom. Always emailing and texting for INTERVIEWER: How long were you married? This patient soon learned to stick to the subject.

Defense mechanisms
We use defense mechanisms to cope with our feelings. Many of these instinctive techniques have been identified; below are a number of the more common ones, divided into groups according to whether they are generally considered to be effective or harmful. Rather than merely stating a definition, well illustrate by a college student upset at being dumped by his girlfriend. Potentially harmful defense mechanisms Acting out. [The student keys the car door of his rival.] Denial. She still loves me; its her mother who turned her against me. Devaluation. Shes actually pretty dumb; I cant imagine what I ever saw in her. Displacement. [The student goes home and starts a fight with his roommate.] Dissociation. [The student awakens in the morning in a strange room, unable to remember how he got there.] Fantasy. Ill write a book, earn a potful of money, and shell beg me to take her back. Intellectualization. I agree with Tennyson, its better to have loved and lost than never to have loved at all. Projection. [Unconscious thought: I hate her.] She hates me. Repression. [The student forgets to return the girlfriends CD collection.] Splitting. Women can be wonderful or horrible; shes one of the bad ones. Reaction formation. [The student thinks: What a bitch!] I admire her for her principles. Somatization. [The student develops chest pains.] I wouldnt have been able to take her out, anyway. Effective defense mechanisms Altruism. I still love her, but I want most for her to be happy. Anticipation: Next time, Ill plan better to protect my feelings. Humor. I called her an angel; she said I was a rat. Maybe we were both wrong. Sublimation. Ill use this time to study hard and complete my education. Suppression. Ill put this on the back burner; Ive got other fish to fry.

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Personal and Social History

As important as social history can be for diagnosis and ongoing care, you should always maintain a healthy skepticism as to its accuracy: memories fade, and recall can be selective. Whenever possible, check the validity of items that seem questionable.

Childhood and adolescence

Ask, Tell me about your childhood. Beyond the bare facts (birthplace, number of siblings and birth order, parents occupations) youll want a general picture of your patients early life. Was this a wanted child in a close-knit nuclear family? Were there any losses from death or divorce? Did your patient have friends and enjoy hobbies and other interests outside of school? Whereas most of these issues are unlikely to make or break a psychiatric diagnosis, they can mold personality and have a lasting effect on adult relationships. How far in school did the patient progress? Were there scholastic or disciplinary problems? Difficulties concentrating or sitting still in the classroom? Childhood hyperactivity with attention deficit is common, and its effects can persist into adult life. Many adults will have sketchy memories of their childhood health, but you might ask about overall health status: Generally healthy? Frequent trips to the doctor? Long absences from school? Parental rewarding of illness behavior with attention can precede some somatoform disorders. Were there any of the common childhood problems: bed-wetting, nightmares or night terrors, obesity, phobias, stuttering, tics? How were they addressed, and what effect did they have on relationships with schoolmates or siblings? When did dating begin? Did any sexual issues begin about this time? Be alert for indications of sexual or physical abuse. Still relatively taboo in everyday conversation, sex information must be actively pursued in a psychiatric interview. You can ease into the subject of abuse by asking, Did you ever feel mistreated as a child? and then request follow-up information, such as type, frequency, source of the abuse and parents reactions to it. A significant minority of psychiatric patients have suffered childhood sexual or physical abuse, which can stand as a precursor to somatization disorder, dissociation, PTSD, and personality disorders, among others.

Adult life
Youll want to know about work history (number and type of jobs, job satisfaction). Have there been periods of unemployment? If so, what was the source of support then? Frequent job changes are typical of antisocial personality disorder; prolonged unemployment can be found in severe mood disorders and in schizophrenia. For women and men, ask about military service: dates, duration, disciplinary problems, and rank at discharge. If the patient saw combat, youll need detailed information to evaluate the possibility of posttraumatic stress disorder. Does your patient now live alone or with someone? In an apartment or house? Has your patient ever been homeless? What is the current financial situation? You can ask, Has money been a problem for you? Ask about leisure activities. Are they pursued alone or with others? How religious is your patient? Has this changed from childhood? Also try to learn something of your patients social support networkthe number and quality of relationships with family and friends. Support issues can help assess your patients chances for response to treatment. Nowadays when we enquire about marital state, we implicitly include relationships with partners of either gender, regardless of legal status. You could start by asking, Tell me about

Interviewing

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your partner. Assess strong and weak points in this relationship, as well as information about past marriages and divorces. How long has the couple been together? What are their relative ages? What have the problems been? How have the patients current mental problems affected the relationship, and vice-versa? For many patients, there is no definable mental disorder, rather two people with mutual problems of living. Youll also need to know about children from this relationship, as well as those of previous ones. Although you can put off asking about sex to a subsequent interview, when you know the patient better, you might forget. Better to bite the bullet and start right in. Could you tell me about your sexual functioning? is a good way to start. If the response is, What do you mean? you can say: Im trying to find out how your sexual functioning is usually, and how its been affected by [the presenting problem]. Youll also want to learn something about early sexual experiences (age and nature, patients reaction to them), sexual orientation as an adult and level of comfort with that orientation. If your patient is in a committed relationship, be alert for some of the problems that typically affect couples: impotence, dyspareunia, premature (or delayed) ejaculation, infidelity, STDs, and concerns about possible homosexuality or bisexuality. Dont forget about legal difficulties. Has the patient ever been arrested? When, and what were the circumstances? What was the resolution? For obvious reasons, people seldom raise these issues spontaneously, so youll have to ask. Legal history can tip you off to personality disorder (especially antisocial) as well as bipolar disorder and substance use issues. Ask for a self-appraisal of the patients own personality (Describe yourself for me.) If this yields a blank stare, elaborate with, What do you like best [like least] about yourself? This fishing expedition could net information that will help you assess self-esteem and characteristics that may have smoothed (or hindered) your patients path through life. Ask about relationships with others and examples of how the person typically copes with stressful situations. Some other possible questions: What sort of situations do people think you have trouble handling? How well do you control your temper? Is there anyoneany type of personyou cant stand? Of course, people may paint too rosy [or gloomy] a personal assessment of personality. A fuller picture requires information from significant others and previous clinicians, but your rough assessment could highlight some of the issues that you need to consider in treating this patient.

Medical History
To be sure, you would pursue the general medical history anywaythats what doctors do. But in psychiatry, it is especially important to learn about general medical symptoms and previous diagnoses, because you will occasionally encounter a patient whose depression was caused by Lyme disease or a psychosis that was the result of an endocrine disorder. Side effects of medications can also produce a variety of mood, anxiety, and even psychotic disorders. Consult standard texts for the specialized review of systems used to evaluate somatization disorder, a chronic illness that affects perhaps 8% of female psychiatric patients (rarely, in men).

Family history
Here, you hope to learn biographical information about the patients relationship with parents, siblings, children and, especially during childhood, any extended family. In addition, and highly pertinent to many psychiatric disorders, is any family history of psychiatric illness, which are usually familial and frequently hereditary. To ensure that your patient understands what youre after, youll need to be explicit. I usually start with a rather long speech like this one:

Interviewing

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Id like to know whether any of your blood relatives ever had a nervous or mental disorder. By blood relatives I mean your parents, brothers and sisters, children, grandparents, uncles, aunts, cousins, nieces, and nephews. Has any of these people ever had nervousness, nervous breakdown, psychosis or schizophrenia, depression, problems from drug or alcohol dependence, suicide or suicide attempts, delinquency, hypochondriasis (define this term if you think the patient wont understand), mental hospitalization, or arrests or incarcerations? Any relatives who were considered odd or eccentric or who had difficult personalities? Move slowly enough through the disorders to give your patient time to consider. And dont accept a diagnosis of schizophrenia, just because thats what family mythology has passed along as the reason for Grandpa Jims mental hospitalizations. Anything this serious demands that you fish around for information about symptoms and response to treatment, so you can make your own evaluation (his psychosis could have been due to bipolar disorder or alcohol dependence).

Control of the Later Interview

At this point in the interview, you want succinct answers to specific questions; what if your patient is still talking about Grandpa Jim? Youll need to encourage brevity without impairing rapport. State your need to move on: Id like to hear about that later, if theres time. Now, lets focus on or Let me interrupt here to pursue something else thats important. Nod or smile approval when you get the sort of brief answer youd like. Make an empathic comment before changing subjects: Your relationship with your husband sounds distressing. Have there been other problems, such as at work? For a patient who continues to ramble, you may need a firm intervention: Our time is a little short Lets stick with the main topic for now By this time, youll be using more closed-ended questionsthose that can be answered Yes or No or with a specific piece of information such as a date or namebut dont completely abandon open-ended questions. Theyre still important for information about emotions and, because they require less work, to give you a breather.

Transitions
Interrogations are no fun, so try to make your interview seem more like a conversation with smooth transitions between topics. You can incorporate your patients own idea or words: PATIENT: my wifes relationship with my son really improved after he got a job. INTERVIEWER: And what about your own relationship with her? Did that improve, then, too? Any common factorplace, time, relationshipcan smooth the flow of a conversation: PATIENT: it was the last time I saw my brother before he enlisted in the Army. INTERVIEWER: And did you have any military service yourself? If you do have to make an abrupt transition, flag it so the patient realizes youre intentionally changing direction: Id like to change gears, now, and ask you about

Interviewing Demonstrate concern for the patients feelings, especially with highly charged questions. A sympathetic facial expression or tone of voice can soften any question.

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With I realize your husbands death makes it hard to talk about him, you acknowledge your patients distress but declare that the topic is important to pursue, anyway. How would you feel if the police picked you up for drug use? Supposition helps your patient achieve some distance from an emotionally charged situation. How do you think other people would cope with a child whos had drug problems? By asking how others would react or feel in a similar circumstance, you can reduce your patients sense of isolation and responsibility. Have you ever had the opportunity to apologize for your behavior when you were drinking? Here, you soften the question by suggesting that chance might have prevented some praiseworthy action the patient should have taken, but didnt.

Resistance
Most of your interviews will be models of cooperation between you and your patient. But some patients may resist giving up certain details of information. Youll recognize resistance by one or more of these features: being late to an interview; voluntary behaviors (poor eye contact, uneasy shifts of posture, changing the subject); involuntary behaviors (flushing, yawning, swallowing); forgetfulness (I dont know about something the patient should remember very well); omissions in the story; contradictions to what was said earlier; silence. Any of these behaviors may be out of anger or lack of trust, or in the service of avoiding embarrassment or criticism, protecting another person. Several techniques can help move the interview around such an impasse: Dont be drawn into the patients anger or other agenda issues. Remember that the issue isnt you, its the patient. Try refocusing the question in slightly altered form: INTERVIEWER: Have you had any ideas you might kill yourself? PATIENT: (several seconds of silence) INTERVIEWER: I was wondering whether youd had the desire to die? Give the patient a degree of control with something like, Just tell me what youd be comfortable saying about [this issue]. Name the emotion you think your patient might be experiencing, with the reassurance that such feelings are normal. Express sympathy. I know its hard to deal with some of this material. Its hard, and its normal, but I do need to understand all about you. This last statement also underscores the medical need for a complete database. Switch the discussion from facts to an exploration of feelings. For a silent patient, try to obtain a nonverbal response firstjust a nod of the head will do.

Interviewing Only as a last resort should you delay the discussion; you want your patient to develop the habit of responding to your requests.

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Sometimes, you can pull information from a reluctant patient by using somewhat riskier techniques. These are often better reserved for use by more experienced interviewers. Offering an excuse for information that could be seen as unfavorable. All that stress probably made you want to drink. Exaggerate negative consequences that didnt happen: Nobody died, did they? Induce the patient to brag: Has there been any behavior for which you could have been arrested, but werent?

Mental Status ExamObservational Aspects

Your evaluation of current mental functioning is the mental status exam. About half of it you obtain by simply observing while you interview; for the balance, youll have to ask questions.

General appearance and behavior

Besides ethnicity, gender, and apparent age, youll want to notice nutritional status (does this patient look anorectic?) and hygiene and clothing (bizarre dress suggests psychosis, a misbuttoned shirt could mean dementia). How alert is the patient? (Drowsiness may be simply due to fatigue, but it could suggest a drug overdose.) A fluctuating level of consciousness could mean delirium. And watch for hyperalertness (excessively vigilant scanning of the environment (found in posttraumatic stress disorder and paranoid disorders). Motor activity could be normal, reduced, or excessive. Overactivity could be the pacing or fidgeting of akathisia, a side effect of the older antipsychotic drugs, but an occasional, uneasy shifting of position or jiggling a leg while seated is usually simple anxiety. Carefully note any other involuntary movements, such as picking at skin or clothing (found in delirium). Mostly, the gestures you notice will be everyday talking with the hands, though some will express unvoiced ideasthe circled thumb and finger OK and the not-so-OK extended middle finger. Watch for tremor (possibly parkinsonism, more often anxiety) or clenched fists. Although depressed people are often underactive, true immobility is pretty rare. It is found in catatonia, a classical feature of schizophrenia but also found in profound depression or frontal lobe dysfunction due to various medical conditions. Note any mannerismsthe unnecessary behaviors that are a part of a goal-directed activity, such as the flourish some people make before signing their names. Mannerisms are common and usually normal. Stereotypies are non-goaldirected behaviors such as crossing oneself without apparent purpose. A person who postures will strike and hold a pose (think Napoleon), again without apparent purpose. A patient who deliberately turns away from you may be showing negativism. In waxy flexibility, the limbs are rigid but you can slowly, with pressure, bend an elbow as if it were a soft wax rod. A patient with catalepsy holds an odd or unusual posture that you physically impose, even after you have said, You can relax, now. Stereotypies, posturing, waxy flexibility, negativism, and catalepsy usually indicate psychosis; they are infrequently encountered today. Facial expression may be normally mobile if your patient smiles, frowns, and otherwise responds appropriately throughout your conversation. A patient who repeatedly glances around

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the room, as if listening to voices or noticing something you cannot see may be experiencing a psychosis. Notice your patients eye contact: gaze riveted to the floor may be due to depression; a fixed stare could mean senility or psychosis. Are there tics of eyes, mouth, or other body parts? Does your patients voice have a normal lilt (called prosody), or is it dull and monotonous? What can you deduce about education or family background from use of grammar? Accent often identifies the country or region in which the person was reared. Does the patient lisp, mumble, stutter, or show any other evidence of speech impediment? Note any mannerisms of speech, including phrases or words used frequently. Is the tone of voice friendly, sad, hostile? You can describe your patients apparent relationship to you along several continua: Cooperative obstructionistic Friendly hostile Involved apathetic Open secretive

Your rapport and the amount of information you obtain could depend in part on how far to the left your patient scores on each of these factors. Also note any evasiveness or seductiveness.

Mood and affect

Some clinicians use mood and affect interchangeably. However, many regard mood as meaning the way someone feels and affect as how that person appears to feel. By the latter definition, which well use here, affect comprises not only stated mood but also eye contact, facial expression, posture, and tearfulness. We use several dimensions to describe mood (affect): Type When you ask, as you should, How are you feeling now? many patients will say, about normal or medium. Others may admit to one of these basic emotions: Anger, anxiety, contempt, disgust, fear, guilt, joy, love, sadness, shame, and surprise. For people who cannot tell you how they feel (alexithymia), suggest some of the possibilities mentioned above. You can also infer much from body language: Anger: clenched jaw or fists, flushed face or neck, drumming fingers, extended neck veins Anxiety: jiggling foot, twisting fingers, affected nonchalance (such as picking ones teeth) Sadness: moistening of eyes, drooping shoulders, slowed movements Shame: poor eye contact, blushing, shrugging In evaluating depression, try to learn whether this mood differs from the grief a person feels at the loss of a loved one. Ask, Did you feel this way when your [relative] died? Lability Although normal people may experience different moods within a brief time span, wide swings are often abnormal. Then we identify increased lability of affect, perhaps going from ecstasy to tears and back within moments. This could be a brief (seconds) depression sometimes encountered in mania or the affective incontinence sometimes noted in dementia. Reduced lability of affect we call blunted or flattened. It is found in severe depression, schizophrenia, and in Parkinsons disease and other neurological illnesses.

Interviewing Appropriateness

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How well does your patients mood match the situation and content of thought? Most of us exhibit inappropriate mood from time to time, but marked incongruity suggests disorganized schizophrenia (e.g., laughing at the death of a parent). Pathological affect (inappropriate crying or laughing) sometimes occurs in pseudobulbar palsy, the result of various disorders such as multiple sclerosis and strokes. Some somatization disorder patients talk about their physical disorders with less concern than you hear on the weather report; this type of inappropriate mood is called la belle indifference (French: lofty indifference). Remain alert for signs of unexpressed emotion, but dont overinterpret. Instead, relate what you observe to what the patient says and to how you think you yourself might feel under similar circumstances. Does the current topic warrant tears? Does your patient appear unnaturally sad? Is that smile genuine or does it seem forced, perhaps to hide true feelings? Intensity You can grade intensity of mood as mild, moderate, or severe (think of the progression from dysthymia through major depression withoutand then withpsychosis). You might also consider whether the mood is fleeting or prolonged, or somewhere in between. Finally, theres the absence of feeling or emotion that we commonly call apathy. It and its fraternal twin, avolition (lacking motivation or desire), are often associated with psychosis and severe depression, but in and of themselves, they are not pathological. Think spring fever.

Flow of thought
How do the patients thoughts move along from one to the next? (Of course, what we actually perceive is the flow of speech, from which we infer thought.) Defects include 1) association (how words are grouped to form phrases and sentences) and 2) rate and rhythm of speech. Psychiatrists often cant agree on where to have breakfast, let alone these definitions. Ive adopted the best consensus view, but you should illustrate your findings with direct quotations. Association Does your patient speak spontaneously, or only in response to questions? If you havent yet had a run of free speech to evaluate the quality of your patients thinking, better ask: I think I could get a better feeling for whats bothering you if you just talk about your problems for a bit. In derailment, sometimes called loose associations, one idea runs into another, possibly related, one so the direction of the words seems controlled by rhymes, puns, or other rulesbut not by logic you can understand. She tells me something in one morning and out the other. Ive got to put the kettle out, my taxi died. Flight of ideas is a form of derailment in which one idea takes off from another, with the patient eventually losing the thread of the original question. Mania patients often have flight of ideas and talk very rapidly (push of speech): INTERVIEWER: Can you tell me about your relationship with your mother? PATIENT: Sure, in our family Mom was king, and King Kong never knocked out New York, my favorite place in the whole world. Thats d-l-r-o-w world backwards, which is where I never want to be, on the back wards. Get it? Tangentiality (or tangential speech) is an answer that seems irrelevant to the question asked:

Interviewing INTERVIEWER: Can you tell me about your relationship with your mother? PATIENT: My golf balls got pink dimples.

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A patient who answers too briefly or who sits speechless shows poverty of speech. When severe, muteness ensues. Poverty of speech can be found in depression, schizophrenia, and occasionally in somatization disorder. You must distinguish it from neurological aphonia. A number of terms describe speech pathology you dont often encounter in clinical interviews. Most occur classically in schizophrenia, but any may occur in psychoses of cognitive origin. When you do encounter an example, be sure to record it with a direct quotation. Thought blocking. The train of thought stops suddenly, before arriving at the station. The patient usually doesnt know why, only that the thought has been forgotten. Alliteration. A phrase includes repetitions of similar sounds. Poets often use it for effect: The street sounds to the soldiers' tread/And out we troop to see (A. E. Housman) Clang associations. The choice of words is controlled by rhymes or other similarity of sound, rather than the requirements of communication. INTERVIEWER: Can you tell me about your relationship with your mother? PATIENT: Oh Mom, poor Mom. Shes calm, a damn warm dam Echolalia. The patient unnecessarily repeats words or phrases. Sometimes subtle, you might not recognize it until there have been several repetitions. INTERVIEWER: Can you tell me about your relationship with your mother? PATIENT: Relationship with my mother. Can you tell me about your relationship? With my mother. Verbigeration. Without obvious purpose, the patient continues to repeat words or phrases. It was deathly still. Deathly. Deathly still. Deathly. Still deathly. Incoherence. Even individual words or phrases appear to have no logical connection: Shovel. . . it wasnt the. . . best hatred. . . lifetime . Sometimes termed word salad. Neologisms. In the absence of artistic intent (such as Lewis Carrolls Jabberwocky Twas brillig, and the slithy toves / Did gyre and gimble in the wabe )the patient makes up words, often from parts of dictionary words. The resulting structure may sound authentic: An Alzheimer patient spoke of rakebucketing in the garden. Perseveration. The patient repeats words or phrases or keeps returning to the same point. INTERVIEWER: Can you tell me about your relationship with your mother? PATIENT: Mom and I were close, real close. INTERVIEWER: And what about your father? PATIENT: Mom and I were buddies. Real close. INTERVIEWER: And your father? PATIENT: Mom was my best friend.

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Stilted speech. Accent, phraseology, or word choice gives speech an unnatural or quaint flavor, such as an American who affects a British accent or uses British idioms.

Bottom line: Take care when evaluating your patients manner of speaking. Because speech patterns can be shaped by cultural or geographic influences, by neurological disorders, and the patients native language, what you hear may carry no pathological significance at all.

Rate and rhythm of speech

Push of speech (or pressured speech) occurs when someone speaks rapidly, often at great length. Loud and hard to interrupt, such patients challenge your interviewing ability. There is often an associated decreased latency of response (the interval between your question and the patients answer). Both of these are typically found in mania patients, who may say that their words cant keep pace with their thoughts. Depressed patients may have increased latency of response, with long pauses between words. There may be accompanying general psychomotor retardation. Disorders of rhythm of speech involve abnormal timing of syllables, such as in stuttering. Cluttered speech is rapid, tangle-tongued and disorganized. Patients with cerebellar lesions may utter each syllable at such a uniform pace that the speech sounds unnatural. Muscular dystrophy may produce speech clusters or difficulty uttering syllables. Some patterns are usually normal: Circumstantial speech. After much irrelevant material, the person eventually comes to the point. Distractible speech. Extraneous sounds or motion may temporarily send the speakers words off in a new direction. Though usually normal, you may note it in mania. Verbal tics. We all use these time-fillers, which are almost always normal (but boring): Y know I go (for I said) Basically Awesome

Mental Status ExamCognitive Aspects

The balance of the MSE requires you to obtain answers to questions, some so basic as to seem insulting. So you should probably start with the brief explanation that you now need to ask some routine questions. The words routine and normal help soften questions that might otherwise be taken amiss. Here are some other steps you can take to motivate your patient: Give positive feedback when warranted. Thats terrific, the best calculations anyones done for me this week. Watch for any distress your questions might cause and respond appropriately. Yeah, mentally subtracting sevens can be hard. Lets give it a rest and try presidents, instead.

Do the formal part of the MSE early in your acquaintanceyou need the data base information, and if you put it off, youre likely either to forget it or ignore it.

Content of thought
This means, the focus of an individuals thought at any given time. For most people, youll note that the content of thought is largely the concern that brought them for evaluation; for most

Interviewing outpatients it will seem pretty normal. However, psychiatric patients can have a variety of thoughts that arent at all normal, some of which you need to ask about. Delusions

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A delusion is a fixed, false belief not explained by the patients culture. By fixed, we mean that you cannot shake the person from the idea. INTERVIEWER: What would you say if I told you that there are no aliens, and they cannot possibly have abducted you into their space ship? PATIENT: Id say you were crazy. INTERVIEWER: Could your idea be due to a nervous or mental problem? PATIENT: No way. I was probed, all right. If the patient agrees that your alternative explanation is possible or says Im just not sure, the idea isnt a delusion. It must also pass the cultural criterion: you wouldnt call a traditional Navajo delusional for believing in witches, nor children who write letters to Santa Claus. Overvalued ideas are held despite lack of proof of their worth. Though not obviously false, logic wont usually dislodge them. Examples include the superiority of ones own gender, race, or religion. Sometimes, as with racial hatred, they interfere with the individuals functioning, causing suffering to the person or to those around. Psychiatric patients can experience quite a variety of delusions: Grandeur. The false belief is that the patient is someone of elevated rank or station (God, Paris Hilton) or has special powers or gifts (enormous wealth, eternal life). Mania patients classically have grandiose delusions, but so do some patients with schizophrenia. Guilt. Especially found in severe depression, sometimes in delusional disorder, the patient has committed some grave sin or error (for which punishment may feel deserved). Ill health or bodily change. A terrible disease has rotted the patients insides or turned bowels to cement. A delusion that the patient has died, sometimes called nihilistic, is an extreme case. Occasionally found in severe depression and schizophrenia. Influence (or passivity). The patients believe theyre controlled from the outside by such influences as radio, TV, or microwaves, or that they control the environment (one patient believed her tears could spawn hurricanes). Typically found in paranoid schizophrenia. Jealousy. The patients spouse has been unfaithfulclassically encountered in alcoholic paranoia, but also in paranoid schizophrenia and paranoid disorder. Persecution. One of the more common types of delusion, the patients belief is in being threatened with harm, ridiculed, or otherwise interfered with. Paranoid schizophrenia. Poverty. Imminent destitution will force sale of the homestead and other property, despite money in the bank or a regular disability check. Severe depression. Reference. These patients notice that people whisper when they pass by, that news media contain special messages for them. A patient thought that when Jim Lehrer on the Newshour said that a settlement was imminent, it meant that he should agree to the property settlement with his former wife. Though found in other psychoses, especially common in paranoid schizophrenia.

Interviewing Thought broadcasting. The patients thoughts are somehow transmitted, perhaps by radio waves. Similar to delusions of mind-reading. Schizophrenia.

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Thought control. Feelings, ideas, or thoughts are put into (thought insertion) or withdrawn from the patients mind. Similar to ideas of influence, with similar diagnostic import. In addition to type, learn all else you can about the delusion. How long has the patient felt that way? What effect has it had on behavior? How does the patient feel about it? Why does the patient think this is happening? (I dont normally like why questions, which often yield little new information. Here, a why question might elicit elaboration of the delusion.) Is the delusion mood-congruentdoes the content fit the patients mood? A severely depressed mans belief that he has gone to Hell and is being tormented by devils is moodcongruent; an angry woman who believes she is Jesus has a mood-incongruent delusion. Moodcongruent delusions are typical of mood disorder, mood-incongruent of schizophrenia. Hallucinations Hallucinations are false sensory perceptions; that is, patients think they perceive something absent any actual, related stimulus. Although hearing is the sense most commonly involved among psychiatric patients, hallucinations can involve any of the traditional five senses. Screen for hallucinations by asking, Do you ever hear voices or other sounds when no one is around to produce them? Do you ever see things other people cannot see? Some patients claim auditory hallucinations when they actually hear only your voice or their own thoughts. Careful questioning can usually sort out these false positives. Ask: Could [this voice] be coming from you, like your own thoughts or conscience? A patient who admits that it could be noises out in the hallway or my imagination probably doesnt have true auditory hallucinations. You can ask, Is the voice as clear as mine? Again, discount no answers. In audible thoughts, the patients own thoughts are spoken so loudly that others can hear. Another confound is the illusion, a misinterpretation of an actual sensory stimulus. It is usually visual, occurs in dim light, and is readily acknowledged once the patient realizes the mistake. A common example: clothes thrown over a bedside chair look like an intruder. Illusions are almost always normal, though patients with delirium or dementia may report them. Try to determine the severity of hallucinations. You can grade auditory ones, for example, on a continuum: Vague noises mumbling understandable words phrases complete sentences. I also like to know whether there is more than one voice, and if so, do they talk to one another, perhaps commenting on the patients behavior (these have been called first rank symptoms of schizophrenia)? Does the patient recognize the speaker? Where is it coming from?The patients head? The toaster? Next door? What is the content of the speech, and how does the patient react? If the voice issues commands, does the patient obey? This last is an important point: patients who obey command hallucinations sometimes cause injuryor worse. You can similarly grade visual hallucinations: Points of light blurred images formed people (how big are they?) scenes or tableaus. You can ask a lot of the same questions, suitably altered, as for auditory ones. When do they occur (only when using drugs or alcohol)? What is the content? How does the patient respond? (It can be pretty frighteningas one of my patients discovered upon looking into a mirror and noting that he had the face of a camel.) Youll especially encounter visual hallucinations in the cognitive psychoses. In the throes of delirium tremens when withdrawing from heavy, prolonged alcohol use, patients may see tiny people or animals. Images linger on the retina in the trailing phenomena that sometimes

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accompany psychedelic drug use. Schizophrenia patients can also experience visual hallucinations, early forms of which may include objects that change size or develop intense colors. Tactile hallucinations (sensations of burning, itching, or of bugs crawling on or under the skin) and olfactory hallucinations (unusual odors, often unpleasant) are likely to indicate the presence of a psychosis caused by physical illness, such as temporal lobe epilepsy.) A woman told me, Early one morning I saw the Devil standing over my bed. I was totally awake but paralyzedcouldnt move my arms or legs! I was so frightened. Am I crazy? Happily, I could affirm her sanity by explaining that she had experienced a combination of hypnopompic imagery with sleep paralysis. They both occur while awakening. That brings up another point: Any interview can be therapeutic. Just telling ones problems to another person is a relief. Sometimes, clinicians can provide reassurance without derailing the information-gathering. Of course, students are unlikely to have this opportunity while they are still learning the ropes, but once youre in practice, you can experience the pleasure of helping another human being with the simplest of devices, the verbal laying on of hands. Anxiety symptoms Fear that isnt directed at (or caused by) something the patient can pinpoint we call anxiety. Usually, there are also unpleasant bodily sensations, along with other mental symptoms that include irritability, trouble concentrating, worrying, and often a brisk startle response. Screen for anxiety symptoms with: Do you feel you worry about things out of proportion to their real danger? Do you often feel anxious or tense? Do relatives or friends call you a worrywart? Follow up by defining when the worries occur, their effect on the patients life, and what helps. A person who suddenly experiences intense anxiety with the rapid onset of sensations such as tachycardia, dyspnea, weakness, and sweating is having a panic attack. Such patients often feel they are about to die or go mad. Screen by asking: Have you ever had a panic attack, when you suddenly felt terribly frightened or anxious? Follow up by learning all the other symptoms the patient might have had, how long the attacks last, how often they occur, and their effect on the patients life. Are attacks associated with agoraphobia, the fear of being away from home or trapped in a public place such as a theater or supermarket and unable to get out? A phobia is any unreasonable, intense fear associated with a situation or object. Specific phobias include air travel, heights, closed spaces, and a zoo-full of animals. Social phobias include speaking or eating in public, using a public urinal, and writing (I hate it when people see my hands shake). Screen for phobias: Have you ever had fears that seemed unreasonable or out of proportion, but that you just couldnt shake? Have you ever been afraid to leave home alone, or of being in crowds, or in public places such as stores or on bridges? Ask about anticipatory anxietyintense, often incapacitating dread that precedes the actual event. An obsession is a dominating thought, belief, or idea (they commonly involve dirt, money, or time). Compulsions are acts the patient performs repeatedly, often to combat an obsession, such as heeding baseless superstitions, counting things, or following rituals. Obsessions and compulsions often go together, no surprise; patients usually recognize them as senseless and often try to resist them. Screen: Have you ever had obsessional ideas? I mean thoughts that may seem senseless to you, but keep returning anyway. Have you ever had compulsionssuch as rituals or routines you feel you must perform over and over, even though you try to resist?

Interviewing Suicide and violence (again)

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Because this topic is so important, I mention it again as a reminder. The screens: Have you any ideas or thoughts of harming or killing yourself? What would it take to make suicide seems less attractive? Regard as ominous any equivalent to the answer, Nothing could. For violence: Have you been feeling so angry or upset that you think about harming someone else? Have you ever had trouble resisting the urge? Positive answers must be followed at once and compared with the historical information you already have. Does the patient have plans? The means (guns, lethal drugs)? A timetable?

Consciousness and cognition

Here, you use approximate (but useful) clinical tests to evaluate the patients ability to absorb, process, and communicate information. I never describe these routine tasks as sillythat risks the question, Then, why do them at all? I also avoid the word simple, which could increase the discomfort of anyone who has trouble answering. Doing poorly on any test can be stressful, so be prepared to support the patient who stumbles: Its hard to do your best under pressure or Most people have trouble with that task. And, always, acknowledge what the patient does well. Attention and concentration By now, you should have a good idea of your patients attention (the ability to focus on a topic or task) and concentration (the ability to sustain focus over time). We sometimes use calculations to asses these qualities. Ask the patient to subtract 7 from 100, then take 7 from the result, and so on. Most adults can finish in less than a minute with fewer than 4 mistakes, but you must take into consideration the persons age, education, culture, and degree of depression and anxiety. I often try to get a rough idea by introducing a subtraction task in the course of my interview. For example, if my patient mentions a date years ago, I might say, And how old would you have been then? If subtractions prove too hard, try a less culture-bound test: Count backward by 1s from 87 and stop at 63. Spelling world backward is asked so often that some patients can rattle it off without thinking, so you might try spelling strap or watch backward (first make sure the patient can spell it forward). Recalling a series of 5 to 7 digits forward, then backward, depends less on education. Reduced attention can be found in conditions such as epilepsy, dementia, head injury, schizophrenia, and bipolar disorder. Much of our mental processing depends on the ability to focus attention; if attention is impaired, interpret cautiously the rest of your MSE findings. Orientation Youll probably already know whether your patient is oriented to person, but you should test time and place. Ask Where are we right now? (City, state, name of facility). If you draw a blank stare, try What sort of a building is this? A museum or The World Trade Center suggests severe pathology, but also consider sarcasm from an angry or uncooperative patient. What is the date? Lots of patients will get the year and month right but be off a day or two. Usually, this is normal, especially for a retired, older patient or a hospitalized person who doesnt have a normal routine to provide cues. If there is any confusion about place or time, evaluate orientation to person: Would you tell me your full name again? Some disoriented patients try to hide their mistakes with made-up responses that sound logical. The process (confabulation) isnt lying, because these people seem to believe what they

Interviewing

26

are saying. For example, a ward patient, asked whether he had ever met the interviewer before, said, Oh yeah! It was last night, down in the bar. You may encounter confabulation in thiamindeficient patients severely impaired with amnestic disorder due to chronic alcoholism. Language Language, the means whereby we use words and symbols to express and understand meaning, includes comprehension, fluency, naming, repetition, reading, and writing. Its assessment is especially important in older and physically ill patients. Hysteria, dementia, and other mental conditions are sometimes misdiagnosed when the patient actually has a disorder of language. Comprehension should be evident from your interview. As a simple test, request this complex behavior: Pick up this pen, put it into your pocket, then return it to the table. Fluency. Watch for hesitation, mumbling, stammering, and unusual emphasis. Problems with naming may be evident from the use of circumlocutions to describe everyday objects. A patient with a naming aphasia might call a watch band The thing that holds it on your wrist or a pen A whatsis for writing. Test repetition by ask the patient to repeat a simple phrase, such as Tomorrow will be sunny. Reading is quickly tested by asking the patient to read a sentence or two. Test writing by asking your patient to write any sentence or one that you dictate.

Screen for aphasias by asking the patient to name the parts of a ball point pen: point, clip, barrel.

Problems on any of these screening tests should prompt a neurological evaluation. Memory We commonly assess immediate, intermediate, and long-term memory. Immediate memory (the ability to register and reproduce information after 5 or 10 seconds) is really a matter of attention, which youve already tested with serial sevens or counting. You can assess it again on your way to testing short-term memory. Name several unrelated items (I use a name, a color, and a street address), then ask the patient to repeat these items. This repetition also provides assurance that the patient has understood you. Should you alert patients that you plan to test them later? One school of thought advises yes, though I dont think Ive ever read the reason why. The other points out that any warning invites cognitive rehearsal, which could mean that a patient benefits from practiceand perhaps pays insufficient attention to the questions you ask in the meanwhile. I prefer not to warn, but the issue may be more cosmetic than cosmicperhaps either methods OK, as long as you are consistent. What you want is a feeling for the range of normal response. Five minutes later, test short-term (recent) memory by asking your patient to recall the three items. Most will repeat the name, color, and at least part of the address. When evaluating the results, be sure to consider your patients apparent motivation. Failure on all three tasks suggests serious inattention due to a cognitive disorder or stress from depression, psychosis, or anxiety. You can best assess long-term (remote) memory from the patients ability to relate the history of the present illness and facility with details of marriages, births of children, and other personal information. Experts disagree about the dividing line between short-term and long-term

Interviewing

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memory, but most agree that between 12 and 18 months some sort of consolidation takes place, so that memories stored long-term are not easily forgotten. Eventually, though, patients with severe dementias such as Alzheimers will lose even long-retained information. Youll encounter amnesia, the temporary memory loss due to physical or psychological trauma, in head trauma, alcohol blackouts, PTSD, and dissociative disorders. It can be hard to ascertainthe natural answer to Have you ever suffered from amnesia? is I dont remember. You might try: Have there been periods of time that you cannot remember at all? Have others ever noticed that you have trouble with your memory? Try to determine whether amnesia is fragmentary (the patient can remember isolated bits) or en bloc (complete loss of memory for that time). You might try to bracket the memory hole with the memories on either side (Whats the last thing you can recall just before the period of amnesia; whats the first thing you can recall afterwards?). You could also ask, Have friends or relatives tried to help you reconstruct what happened? Dont assume that a memory hole means something bad happenedclinicians have come to grief persuading patients that amnesia implies assault or molestation, the notorious false memory syndrome. Cultural information These tasks mainly assess the patients remote memory and general intelligence, so some texts dont even mention them. They are, however, a traditional part of the mental status exam: Who is president now? Who was just before? Most patients can name four or five presidents, working backward. If one is omitted, its fair to try to jog your patients memory. Lets see, did you leave out anyone? or, Hes hiding between two Bushes. Other cultural tests are to name the governor of the state, five large cities, or five rivers. You can also get a pretty good idea of your patients intelligence, memory, and interests by asking about current sports events, candidates in the next election, and other cultural items. Abstract thinking The ability to abstract a principle from a specific example is another traditional task that depends heavily on culture, intelligence, and education. Commonly used abstractions include proverbs, similarities, and differences. What does it mean when someone says that people who live in glass houses shouldnt throw stones? Can you tell me what this meansA rolling stone gathers no moss? Note that some proverbs have more than one interpretation (moss-gathering might be regarded as either a positive or a negative). Accept any logical interpretation. Similarities and differences are somewhat less culturally bound than proverbs, so you are probably better off asking some of these: How are an apple and an orange alike? (Both are fruit, spherical, have seeds.) How do a child and a dwarf differ? (A child will grow.)

Insight and judgment

Insight refers to your patients ideas about what is wrong. It may be evident, but you can ask: Do you think there is something wrong with you?

Interviewing What kind of illnesses do people come here to get treated for? What are some of your strengths? Do you think you are impaired in any way?

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Insight may be full, partial, or nila mania patient with partial insight might realize that something is wrong but blame others for it. Insight also tends to deteriorate with worsening illness and to improve during remission. Poor insight is typical of cognitive disorders, severe depression, and any of the psychoses. Patients assessment of their own strengthswhat they think they are good atcan be important for recommending treatment and estimating prognosis. Evaluate your patients selfimage with: What do you like about yourself? How do you think others people see you? Judgment is the ability to determine an appropriate course of action to achieve realistic goals. Some writers still recommend assessing judgment with hypothetical questions such as What would you do if you found a letter with a stamp on it? or How would you react if a fire broke out in a crowded theater? I avoid such questions, which probably have little bearing on real patients in the real world. In the final analysis, your best appraisal of judgment may come from the history you have just obtained. Or ask: Do you think you need treatment? What do you expect from treatment? What are your plans for the future?

When Can You Omit the MSE?

Because you derive much of the MSE by observation alone, the real answer is, Never. What Im really asking is, Can a clinician safely avoid asking the questions contained in the cognitive portion of the mental status exam? For students, the answer is No, because you should be learning what to ask and what answers to expect from normal (and abnormal) people. But an experienced clinician will sometimes omit the formal questioning when faced with an outpatient who presents a well-organized history or when the results of formal testing are available.

Further Learning
Interviewers on TV or radio provide a terrific opportunity to study interview technique sometimes to experience the opposite of what I recommend. Im thinking of certain talk or news show hosts whom you can catch asking double questions, leading questions, questions so complicated that you cannot follow the thread. Sometimes, youll encounter all of these elementary mistakes in a single, Byzantine utterance. Great fun for professional interviewers (viz., all of us) to use as examples of how not to elicit information. You can get much more information on interviewing from a couple of books, both of which youll find in the OHSU library. The Clinical Interview Using DSM-IV-TR, by Ekkehard Othmer and Sieglinde C. Othmer is in two volumes. Volume 1 covers the fundamentals of interviewing, whereas volume 2 introduces more specialized techniques for difficult patients who are psychotic, cognitively impaired, deceptive, or who may use symptoms as meta-languagesuch as those with conversion, dissociation, posttraumatic stress, and somatization. A one-volume approach is taken in The First Interview, from which the chapter above was prcised.

Chapter 2

Making a Psychiatric Diagnosis

Until the middle years of the Twentieth Century, psychiatric diagnosis was pretty much a freefor-all. If psychiatrists followed any rules at all for making a diagnosis, they were likely to be idiosyncratic and based on intuition, not science. The realization that this Wild West approach to diagnosis was producing some unhappy results for American psychiatrists (and their patients) led to a philosophical sea change. Well briefly explore two aspects of this paradigm shift.

The DSM-IV system of diagnosis

In the 1970s, the USUK Cross-National Project determined that American psychiatrists were far more likely to diagnose schizophrenia in any given psychotic patient, whereas British psychiatrists tended to favor bipolar disorder. Researchers reexaminations of the patient records using a conservative definition of schizophrenia largely agreed with the British clinicians diagnostic impressions. This finding reinforced a movement, championed by psychiatrists at Washington University in St. Louis and other research institutions, to discover patient characteristics that allowed reliable groupings. The features that were identified for many categories of patient provided the basis for what eventually became DSM-III, the first diagnostic manual that stated criteria for diagnosis. But, wait a minute, why do we need criteria, anyway? Other medical specialties dont count symptomsfor a broken femur, for example, or tonsillitis. Psychiatrists use criteria partly because we have so few definitive laboratory or imaging studies, partly because there are too many matters about which clinicians would not otherwise agree. The hard-headed demand that conditions we diagnose meet strict criteria also helps us avoid those diagnoses that are too vague or too ill-studied to have predictive value. Thats why we count things. Those Washington University psychiatrists (and researchers today) validated the syndromes they identified with follow-up studies on the premise that, years down the road, validly diagnosed conditions wouldnt morph into something else; a schizophrenia patient would still have schizophrenia, not bipolar disorder or a substance-related psychosis. With that assurance, we can achieve the intended purpose of any diagnosis: to make accurate predictions of what to expect in the future. Specific goals include predicting treatment outcome, judging which family

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Diagnosis

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members are at risk for similar diseases, explaining the natural history of the disorder, and helping patients understand their options. Our current diagnostic system comprises over a hundred categories of mental disorder, most (but not all) of which have been identified in careful epidemiologic studies. Of course, it has flaws, despite which DSM-IV remains the best system yet devised. It includes five information areas, each called an axis: Axis I
Mental disorders. Requiring strict criteria, these include every category of mental diagnosis, such as mood, psychosis, cognitive, and substance use disordersall except * the two listed on Axis II. Personality disorders and mental retardation. Listing these on a separate axis helps ensure that they wont be overlooked. Each requires criteria.* mental condition or treatment.*

Axis II

Axis III Physical conditions and disorders. Some of them may have a bearing on our patients Axis IV Psychosocial and environmental problems. These are the events and conditions (e.g.,
economic, housing, job, legal, interpersonal) that could influence the diagnosis or management of psychiatric patients.

Axis V

Global assessment of functioning (GAF). This scale reflects overall social, work and psychological functioning; it is most useful in tracking a patients progress across time. 90100 Functions well in a wide range of activities; no symptoms 8190 Few if any symptoms; good functioning in all areas 7180 Any symptoms are transient and expected reactions to stressors; slight, if any, job, social impairment 6170 Some mild symptoms or some problems in functioning 5160 Moderate symptoms or moderate problems in functioning 4150 Serious symptoms or serious impairment in functioning 3140 Some impairment of communications or reality testing or major impairment in several areas (work, judgment, thinking, family relations) 2130 Behavior shaped by delusions/hallucinations or seriously impaired judgment or communication 1120 Some danger of harm to self or others or failure to maintain minimal personal hygiene or grossly impaired communications 110 Persistent danger of severe harm to self or others or persistent failure to maintain personal hygiene or serious suicidal act 0 Inadequate information

Youll find numbers (and a few letters) tacked onto the diagnoses associated with Axes IIII. These are coding devices for the folks in the record room; we dont need to worry about them here.

The DSM-IV manual includes numerous GAF examples.

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Heres how we might use the 5-axis structure to describe a patient. Lets say this is the inmate of a jail, a man who has had schizophrenia for the past 12 years and who has for several years been heavily using alcohol. He is a lifelong loner with no friends who, under the influence of auditory hallucinations, broke into a church and desecrated the altar. Assuming that our interviews and reviews of available information had validated the impressions stated above, heres how wed report our evaluation: Axis I Axis II Axis III Axis IV Axis V Paranoid schizophrenia, chronic Alcohol dependence Schizoid personality disorder None Currently in jail No network of support GAF = 25 (current)

However, just knowing the skeleton, even if you can flesh it out with diagnostic criteria, isnt nearly enough. On a given day, you could conceivably find enough symptoms in most patients to suggest a variety of diagnoses that wouldnt necessarily be correct. Hence, need for a welldefined diagnostic procedure.

Diagnostic procedure
A big problem with the DSM-IV is that too many clinicians have come to assume that simply collecting a batch of symptoms relieves us of responsibility for any real thinking. Here in the 21st Century, thats just plain wrong. Repeated studies have shown that experienced psychiatrists tend to make a diagnosis within the first 3 minutes of the initial interview. This is terrific efficiency, but it puts us at enormous risk for error. Once weve decided about anything, human nature causes us to look for information that will reinforce that decision rather than call it further into question. Our initial impressions, our past experiences, and our expectations combine to endanger future objectivity. One antidote to this sort of choice-based blindness is to follow a careful routine when evaluating each new patient, then scrupulously observe each returning patient for new information. Of course, there is no such thing as a fail-safe diagnostic process. But following the outline below should help ensure that you considerand reconsiderall the relevant material. Assemble a complete database. Collect all relevant information from 1) interviews with the patient, 2) collateral interviews with relatives, 3) medical records and other healthcare providers, 4) laboratory, imaging, and psychological testing data Identify all relevant syndromes. These may include a variety of disorders, including mood, anxiety, psychotic, substance use and many others. Many patients will have elements of several syndromes. Create a wide-ranging differential diagnosis that includes all possibilities. Each of the types of syndrome you identify could have a variety of causes. So, a mood disorder could be due to major depression, dysthymia, substance use, physical illnesses, and so forth.

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Arrange your differential diagnoses in the order of a safety hierarchy. That means, at the top those conditions that most urgently require treatment, are most likely to respond well, and have the best outcome. Choose your best diagnosis, but constantly reevaluate as new data emerge. Keep your mind open.

Differential diagnosis and the safety hierarchy

A wide-ranging differential diagnosis is vital to the evaluation of any patient, a rule to which psychiatric patients prove no exception. In any differential we should list the diagnostic possibilities so as to expose our patients to the least possible riskof perils such as social stigma, treatment that is inadequate or downright harmful, prognosis that is wildly inaccurate, or social interventions that are inappropriate or unnecessary. A safety hierarchy places at the top those conditions that most urgently require treatment, are most likely to respond well, and have the best outcome. A safe diagnosis is one that youd prefer for yourself or a family memberif it turns out to be correct and leads to effective treatment. Most especially you should consider the possibility that any disorder could be due to a medical illness or substance use, but recurrent depressions and even bipolar mood disorder also belong in this category. At the bottom are conditions where a terrible prognosis makes treatment seem unlikely to make much differencedisorders like AIDS-related dementia, Alzheimers, and antisocial personality disorder. Although schizophrenia can be managed successfully, it is often difficult to treat and it sometimes results in agonizing years of disability. Everything else goes somewhere in between, though clinicians can (and do) argue about the exact order. But most important still is to consider first those psychiatric causes related to substance use or medical illness.

Further Learning
For the official word on current American psychiatric diagnoses, the latest edition of the diagnostic and statistic manualDSM-IV-TRprovides 900 pages of light reading for a Saturday night. (TR stands for text revision, which means that the supporting text reflects the latest research; there are also a few minor changes to the criteria for just 3 diagnoses.) If you prefer the shorter, nonofficial version with case histories, there is a copy of Morrisons DSM-IV Made Easy in the OHSU library. Peculiarly enough, the diagnostic process is something that most psychiatric texts dont pay much attention to. Diagnosis Made Easier comprises what Ive learned in 40 years about sifting information to make a psychiatric diagnosis. Theres a copy in the OHSU library.

Chapter 3

Depression
It was the insomnia that got my attention, Suzanne told her PCP. Ive always slept like I was drugged, so when I kept waking up at 3 in the morning, I knew something had to be wrong. Recently Suzanne had become listless, losing interest in things she usually enjoyed. I used to have a passion for bridge; now it seems so trivial. I havent got much energy for anything; I just sit and stare out the window. I feel like Ive lost my life. After a medical checkup revealed she was physically healthy (and that she had never used alcohol or drugs), Suzanne was referred to a psychiatrist, to whom she repeated her story. Ive never felt depressed and worthless like this before, she said, fighting back tears. I dont even want to talk on the phone with my friends, let alone see them. Though her weight hadnt changed, she had little appetite; she had stopped cooking, a favorite hobby, and now relied on fast food and TV dinners. Jack, her husband, wondered if she needed a change: perhaps she was just lonely (they lived far out in the desert, and she didnt drive). However, being with people didnt help her shake off the constant fatigue. She said shed never before felt so miserable and often found herself crying over nothing. For about 5 months, she said, the stress of her jobshe worked at home for a dotcom marketing firmhad been getting to her, so shed cut back to part time. And Ive been so irritable with Jack, Im lucky he didnt just leave me. Instead, he had urged her to seek help, had even made the call for her. I didnt have the energy to dial the phone. The term depression embraces a variety of meanings. For some, it may be nothing more than a gentle sadness; for others, it is a profoundly painful gloom. It can last just a few days or weeks or many months or years. Some patients experience physical symptoms, such as crying, difficulty with sleep, changes in appetite and weight, even pain or weakness.

Symptoms of depression
Clinically depressed patients will experience a number of symptoms. Some are almost guaranteed, whereas others are less common. Though most people wont have them all, 9 core

33

Depression symptoms are listed below. Note that to qualify as diagnostic criteria for major depressive episode or dysthymia, these symptoms must be present most of the time, nearly every day.

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Depressed mood. The patient feels sad or some equivalentmournful, blue, despondent, anguished, or simply downor other people think the individual looks depressed. Like Suzanne, many patients cry a lot; time passes slowly and everything looks gray. Clinical depression lasts most of the time for at least two weeks; usually, it goes on for months. Loss of interest or pleasure. Patients care less about activities they used to enjoy. In Suzannes case, it was cooking, but hobbies and interests such as reading, watching TVeven having sextypically fall by the wayside. Problems with appetite and weight. Classically, when loss of interest extends to food, appetite declines and weight drops. However, some depressed people have increased appetite or eat so much more than usual that they gain weight. Problems with sleep. Patients struggle to fall asleep, or they awaken throughout the night or (like Suzanne) too early in the morning. Then they feel tired and grouchy during the day. However, some depressed people instead sleep more than usual (hypersomnia). Fatigue. Even with good sleep, depression is wearing; tiredness makes it hard for the patient to perform everyday tasks. Change in activity level. Many depressed people become restless, so agitated they cannot sit still (pacing, pulling hair, wringing hands). Depression slows others down; some, like Suzanne, do little more than sit. Low self-esteem. In a depressed state, patients may feel nearly worthless (Suzanne did). Guilt feelings make some feel that life has been a failure, that they have let everyone down. They may wish they had been better people or done things differently. Poor concentration. When all thoughts are painful, its hard to focus on your responsibilities and other important matters. Even trivial decisions come to seem impossibly complicated. One patient said that just maintaining a thought was like trying to grasp a piece of soap that kept squirting away. Thoughts of death. Repeated thoughts about death (not just the fear of it) can escalate to suicidal ideas, plans and attempts. Of course, youll encounter plenty of other symptoms, but most of these are more often found in disorders other than depression. Crying spells is one such symptom; irritability is another. Some patients complain of physical issues such as headache or an upset stomach, to the point that somatic symptoms have at times been regarded as depressive equivalents. In any event, only the symptoms boldfaced above qualify as criteria for a DSM-IV mood disorder.

Depression severity
Some depressed patients become acutely psychotic. They may experience hallucinations (tableaus of torture victims or accusatory voices shouting that the patient is evil). Severe guilt feelings can evolve into a delusional belief that they deserve to suffer for their sins; a few even believe they had died and gone to hell. (Note how these delusional beliefs are nearly always egosyntonic, meaning that the content of the delusion mirrors the persons mood.) Some patients feel

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completely hopeless, perhaps concluding that they are forever condemned to their own personal corner of hell, where things will never improve. Such descriptions are dramatic, even iconic, but in their extremity they only fit the small minority of depressed people. Severity is determined by a combination of several factors: the number of symptoms, their intensity, and the effect they have on patients and those around them. Mild. Patients who are mildly ill will have just a handful of the symptoms listed above barely enough to qualify for a major depressive episodeand theyll cause only minimal inconvenience. These patients will probably still sleep and eat pretty well, and theyll continue with work and family life. Moderate. As more symptoms accumulate, they begin to dominate the persons life. Insomnia yields daytime fatigue; failing appetite causes weight loss; guilt feelings crowd out other thoughts. Those who still go to work dont get much done; perhaps they fight with fellow workers, or avoid them altogether. The future seems bleak; they begin to have gloomy thoughts about death. Severe. Still more symptoms, increasingly extreme. These patients may plan suicide or make actual attempts; feelings of unreasonable guilt expand and deepen. Sleep becomes a nightmare, appetite is gone; likely, the patient takes sick leave from work or school. Hallucinations or delusions may appear, as described above.

Differential diagnosis
The presence of depressive symptoms isnt by itself a real diagnosis. A DSM-IV diagnosis of any of the depressive disorders requires that other conditions be met. These additional factors assure us that this particular patient qualifies for a category that has been studied and vetted enough that we can predict such issues as outcome, response to treatment, and the likelihood of illness in blood relatives. Following is a differential diagnosis in which the numerous depressive disorders are ordered in a rough safety hierarchy (see page 32). Depression due to substance use Depression due to a medical condition Bipolar I or II Major depressive disorder Atypical depression Psychotic depression Recurrent depression Seasonal affective disorder Dysthymic disorder Adjustment disorder with depressive features Normal?

Major Depressive Episode and Disorder

The evaluation of any mood disorder should occur in steps. The first is to determine whether one of the 4 mood episodesmajor depressive, manic, hypomanic, or mixedis present (well discuss the last 3 of them in the next chapter). In the case of any of the depressive disorders, we are looking first for evidence of what DSM-IV calls a major depressive mood episode.

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Major depressive episode

The first requirement for identifying a major depressive episode is a significant mood change. Patients feel depressed, down, blue, or some similar description, and almost always theyll agree that its a distinct change from normal, not just a worsening of how they usually feel. A few people dont recognize just how unhappy they are; they may only identify a loss of pleasure or interest in activities they used to enjoy. For a DSM-IV diagnosis, the depressed mood (or loss of pleasure) must be present most of the day, most days for at least two weeks. Some patients (mostly, older people) will think the problem is something physicala severe headache or abdominal painwhich earns the term masked depression and can require careful questioning to reveal the real problem. Including the low mood or loss of pleasure, there must be a total of 5 of the typical depressive symptoms listed on page 33. Suzanne reported 6 of these: feeling depressed and worthless, loss of pleasure, low energy, trouble sleeping, poor appetite, and loss of interest in her usual activities. Her thoughts were gloomy (she felt she had accomplished nothing with her life), though she wasnt so seriously ill that she had psychotic symptoms or thoughts about dying. She noted that how she felt was markedly different from how she formerly felt. With the patients collection of symptoms identified, the work is only partly done. Several other qualities must be noted: the symptoms must occur for (1) a minimum time duration resulting in (2) clinical distress or impairment of work, social life or personal functioning and (3) from which are excluded conditions brought on by the medical illness, the use of substances, bereavement within 2 months, and any episode intermixed with mania. Now weve defined the major depressive episode (see Table 1).

Major Depressive Disorder

And now to the diagnosis of Suzannes actual mood disorder. Suzannes doctor noted that this was her first episode of depression; that she had no substance abuse or medical disorder that could explain her symptoms; that she hadnt been depressed long enough for a diagnosis of dysthymia; and that shed never had an episode of mania or hypomania. She also didnt have symptoms that would make us think of schizoaffective disorder. This longitudinal information indicated that she had a single episode of major depressive disorder (MDD)see also Table 2. Note that there are several steps to the diagnostic process. After identifying the type of mood disorder, you can add specifiers that apply to the current or most recent mood episode. This verbiage is valuable in that it can let the next clinician down the road in on your thinking about such clinical symptoms as melancholia, catatonia, and atypical features, and about the course of illness (postpartum onset, full recovery, rapid cycling, and seasonal pattern (Table 3). You dont have to include this stuff, but it might be helpful to someone down the road.

Course of illness
Major depression usually begins slowly and worsens over the course of a few weeks. Sometimes, the patient pinpoint when it began, though you might be able to approximate it by asking, When did you last feel well? Untreated (which happens far too often), most depressions last several monthsperhaps nine, on averageand resolve with a complete return to previous level of functioning. Patients who dont recover completely follow one of two general patterns: some

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improve, but retain a few, low-grade symptoms of depression (partial remission), whereas others may remain chronically depressed for years.

Epidemiology, etiology and comorbidity

Because everyone feels sad from time to time, you might think that depression is universal. But, though more people suffer from depression than any other mental health disorder, the number with diagnosable mood problems is still far below 50%. In fact, incidence estimates occur along a fairly wide spectrum. Various studies find the incidence for women ranges from 1025%; men come in at just about half that. (In children, boys and girls are about equally affected; and we just dont know the answer behind these sex differences.) It usually begins in the 20s or 30s, but children, adolescents, and senior citizens are also at risk. There is no relationship to race, socioeconomic status, or marital status. Major depressions are reported in all countries in the world. In the United States alone, direct costs of depression range upward from $12 billion each year; lost wages and other indirect costs exceed $30 billion annually. An enormous volume of research has explored the many theories about the etiology of depression. The important current thinking includes the following: Genetics. Having a relative with depression enhances your own risk; identical co-twins of depressed probands have about 4 times the chance of depression as do fraternal co-twins, strongly supporting the role of genetic inheritance. In general, the relatives of patients who have only depression (no mania) also tend to have just depression, but there is some overlap, and the exact relationships have yet to be determined. Overall, heredity explains half to two-thirds of the risk of depression. Brain chemistry and structure. A variety of neurotransmitters have been suggested as mechanisms for depression, though thus far, the evidence has been largely indirect. For example, for over 40 years it has been known that the tricyclic antidepressants (TCAs) inhibit reuptake of norepinephrine at presynaptic nerve terminals and that monoamine oxidase inhibitor antidepressants inhibit its breakdown once it has been released into the synaptic space. More recently, the effectiveness of selective serotonin reuptake inhibitors (SSRIs) in treating depression have implicated serotonin as another neurotransmitter responsible for depression. The brains of suicide victims have been found to have fewer than normal type 2 serotonin receptors, and the CSF of severely depressed patients are short of 5-hydroxyindoleacetic acid (5-HIAA), an important metabolite of serotonin. A number of studies (PET, MRI, and drug treatment) implicate the subgenual cingulate area (Brodmann area 25) in patients with melancholia and other forms of major depression. In the past several years, small series of previously refractory depressed patients treated by direct deep brain electrical stimulation to this part of the brain have reported an immediate lifting of mood. Loss. A person who loses a parent or other important figure or who suffers any other major disappointment in life (think job loss, rejection by a lover) may develop depressive symptoms. How can we explain the possible etiologic role of loss and other stress? The stressful event might precipitate the release of, say, cortisol, unleashing the depressive symptoms, which then run their course. Fanciful? Yes, but plausible, though we need to make an assumption to account for the fact that, in most studies, only a minority of those who have suffered a loss (such as bereavement) will report symptoms of clinical depression. So we must postulate that our

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depressed person has a tendency (perhaps genetic, perhaps created early in life by abuse, loss of a parent or other harsh environmental factors) to react negatively to stress. Depression as Learned Response. Perhaps some people learn depression from past experiences where they could not avoid unpleasant situations. Repeated failure in childhood to master skills (mathematics or a musical instrument, for example) might put that individual at increased risk for depression later in life. Somewhat related is the cognitive theory of depression, in which people think of themselves in negative termsfeeling that they are worthless, helpless and hopeless, citing anything bad that happens as proof of their own incompetence. The cognitive model has inspired innovative psychotherapy, such as cognitive-behavioral therapy (CBT) and its variants, directed at major depressive and other disorders. Of course, many of these hypotheses are compatible with other theoriesfor example, the chemistry of the brain can be used to explain the final common path for depressions resulting from any of the above causes. In all likelihood, no single theory will ever account for every depression; clinicians should consider many explanations when evaluating patients. Other major mental disorders, especially panic and other anxiety disorders often occur in patients with major depression. During an episode of depression, some patients develop symptoms of obsessive-compulsive disorder. Alcoholism and the misuse of other substances are also highly comorbid, in which case it is often important to determine which came first: depressions that occur secondary to the onset of substance use require a different treatment plan. Depression that on its surface can appear no different from major depressive disorder occurs with somatization disorder; then, too, a different treatment approach may be neededone that deemphasizes physical treatments such as medication.

Treating major depression

Even without treatment, depressive disease tends to linger for months and then melt away. The problem is, a lot of damage could be done if depressed people just waited for their symptoms to subside. We think of treatment in terms of three phasesan acute phase (the first few symptomatic days or weeks), a maintenance phase, and, for many people, prevention of future episodes. Acute phase The choice of acute treatment hangs on four factors: its availability, the severity of the symptoms, what treatments have previously helped, and the patients preferences (for example, dislike of medication, or too busy for psychotherapy). For mild to moderate depressions, either psychotherapy such as CBT or medication can be effective. Suzanne had to depend on others for transportation, so her brief list of symptoms and personal preferences led to a trial on medication. Balancing effectiveness against side-effect profiles, the best first choice for a mild to moderate depression is usually venlafaxine (Effexor), bupropion (Wellbutrin), or one of the SSRIs. Suzanne started the SSRI citalopram (Celexa) at 20 mg/day, doubled it after a week when she felt no improvement. Within another 10 days her mood had brightened; soon she was working full time again. For those who, due to side effects or previous lack of effectiveness, cannot take one of the above drugs, an older drug such as desipramine (Norpramin) or nortriptyline (Pamelor) is a reasonable choicethese have fewer side effects than most other TCAs. As with most drugs,

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start low and increase slowly to minimize side effects. After a couple of weeks or so, reassess the situation with the patient: Is a response beginning? What is the extent of side effects? These questions help determine whether to increase the dose or try a different medication. Generally, several weeks on the usual therapeutic dose of any drug is needed to assure that the trial has been adequate. In mild to moderate major depressions, psychotherapeutic interventions such as CBT and interpersonal psychotherapy can be as effective as medication. Psychoanalysis and psychoanalytic psychotherapy are too slow, too expensive, and too unsure to use as the main treatment for depression. And for the more severe forms of the illness, medication or other somatic treatment is almost always indicated. Whether or not formal psychotherapy is used, patients should be cautioned against making any big decisions or major life changes when depressed. For example, one person might be tempted to relieve depressive thoughts by the high that comes with a marriage proposal or having a baby; another might seek distance from a spouse through divorce or separation. Patients should understand that big decisions can have big consequences, and that their decisions could look quite different once the depression has lifted. In most cases, this will require from 3 to 6 weeks, once treatment begins. To treat more severe depressions, many clinicians combine medication with psychotherapy. They do this for several reasons. First, the worse the symptoms, the more troubled the patient, and the more a clinician worries that things could worsen rapidly. A two-pronged approach has a better chance of arresting a downward spiral. Second, because you dont know how effective any treatment will be until you try it, using two approaches hedges your bets. Third, people seen frequently in psychotherapy have more chances to ask questions and have their doubts addressed, which makes it more likely theyll follow their therapy regimens carefully and remain in treatment. CHOOSING TREATMENT Here are some factors to consider when choosing a treatment for depression: Target symptoms. These are the problems that most need to be addressed. If the patient is agitated or has insomnia, avoid SSRIs and consider more sedating drugs, such as mirtazapine (Remeron), nefazodone (Serzone), or a TCA like Elavil. For atypical symptoms, such as excessive sleepiness and increased appetite, SSRIs or MAOIs may work well. Symptoms that appear regularly each fall or winter suggest bright light therapy as a first course of action. Severity. For a mild or moderate depression, consider one of the specific psychotherapies or a newer medication such as citalopram or (sertraline) (Zoloft), which have fewer side effects and drug-drug interactions. A more severely depressed patient may respond better to a TCA or venlafaxine; also consider combining medication with CBT. For a really severe depression (symptoms of psychosis, profound weight loss, or severe risk of suicide), you might want to go straight to hospitalization and ECT. Side effects and interactions. Someone who is troubled by sexual dysfunction, whether as a symptom of depression or as a side effect of another antidepressant, might do better with nefazodone or mirtazapine. Bupropion doesnt usually cause weight gain, sexual dysfunction, sedation, or anticholinergic effects such as dry mouth and constipation, and it may also be less likely to precipitate mania. Bright light therapy has few side effects, and the psychotherapies have almost none at all. For someone who must take a lot of other medications, consider venlafaxine or mirtazapine, which have few interactions with other drugs.

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Associated diagnoses. For a depressed person who also has another psychiatric disorder (such as obsessive-compulsive disorder or bulimia), treating the other disorder may address the depression, too. For someone who misuses substances, first address that problem. For depression plus an anxiety disorder, consider paroxetine (Paxil) or sertraline but not bupropion. Previous episodes. Because past behavior is the best predictor of future behavior, if a previous episode of depression responded well to a treatment X, then X is a reasonable starting point for treating a subsequent episode. Compliance. Patients who have had trouble complying with treatment should be seen weekly and closely questioned about what medications they are taking, and how often. Biopsychosocial. Although some patients need only one or two legs of the classic mental health treatment three-legged stoolthe biopsychosocial approach to healthcareremember that a job, legal, housing, or other social problem could necessitate referral for social support. For these patients (and their families), this referral could prove to be a vital part of the treatment process. FOLLOWING UP TREATMENT For most depressions, the patient should return for a second visit within a week or two. At that and subsequent visits, youll need to: Obtain any additional information that was overlooked on the first interview. Theres almost always some of that. Ask about changes in target symptoms. For example, once sleep disturbance or poor concentration begins to recede, improvement is on its way. Of course, they could be getting worse, which would also attract your attention. Assess side effects of treatment. How bothersome are any that have appearedenough to require a dose adjustment? A trial on something different? Address the effects of stressors. Family problems, marital discord, illness of friends, and many other stressful events can complicate the life of someone who is battling depression. Provide family education and support. Relatives who know about the illness, including medications and side effects, can help assess progress and watch for evidence of relapse. Plan for future visits. How frequent should your psychotherapy visits need to be? If someone else provides psychotherapy, all clinicians should communicate frequently. To guard against relapse, Suzanne took her medicine for another 6 months, then gradually reduced it to zero. A year later, off medicine, she was feeling welland had even learned to drive on the freeway. Maintenance phase If all goes well, for the half year or longer of the maintenance treatment phase, you should probably not change anything. For patients who start to lose ground, a first step would probably be something as simple as a small increase in medicationthis worked for over half the patients in one study who, after initial improvement, had become symptomatic again. If this is ineffective or impractical (due, perhaps, to side effects), changing medications or starting psychotherapy may prove effective. In any case, it is vital to impress upon the patient that, even if doing well, it is important to be seen at intervals. During the maintenance phase, some patients will report a sudden changefor the betterin how they feel (It was like someone threw a switch). From that moment on, they knew that

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they were no longer ill. With this experience, they can stop treatment. However, for most patients, after 9 months or so youll need to begin a medication taper to see whether they can get by with a smaller amount. Tapering has two advantages: (1) If symptoms reappear, theyll probably be mild and manageable, and (2) it minimizes discontinuation side effects that are so common with psychotropic medications. Prevention Preventing future episodes is especially relevant for patients who have repeated episodes of depression. Well discuss them later (page 45).

The physicians approach to the patient

What not to say There are dozens of things a depressed person doesnt want to hear, because they seem unbelievable, insincere, or impossible. Such statements are often made by caring people who have no conception of what a depressed patient is going through. Here are some of the more common statements that relatives (and sometimes physicians) make that dont work well: Nobody promised life would be fair. If youd just try, you could pull yourself out of it. Everyone feels down once in a while. Lots of people have worse problems than you do. You have so much to be thankful for. Go shopping. That always helps me when I feel down. Depression, happinessits all choices you make. I know just how you feelI have a bad day now and then myself. What you need is a [job] [romance] [new car] [hobby]. Just snap out of it. What patients might need to hear On the other hand, here are some sentiments a depressed person might find entirely appropriate, even helpful, especially from a loved one. Of course, whatever one says should be heartfelt, and no one should make promises they cannot keep. Ive known dozens of people whove had depression, and they got well. If you had to have a mental disorder, you picked the right one. And you might advise the family to try: Your doctor says that youll get over this and be well. And I believe your doctor. I cant imagine feeling the way you do, but I can feel how much you are hurting. Call me anytimeIll respond. Its OK to [cry] [be depressed] [feel angry], Ill still care. Ill see this through with you. You are so important in my life. I know you cant help the way you feel, and it wont change the way I feel about you. When we get through this, well still be together. I love you.

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Atypical Depression
In the type of major depression called atypical, certain symptoms (especially appetite and sleep) are different from the classical picture. Although everyone always called her the ideal mother-in-law, following her sons divorce Alice began to blame herself. She brooded that she had spent too much time worrying about herself and not enough time making her sons wife feel welcome in the family. For more than a month now, she had felt all fuzzy most of the time, like I needed to clean off my glasses, but I wear contacts. Alice had begun to neglect her two teenaged children and couldnt care less about her job as a florists assistant. Id plop the flowers into a glass of water, and if they didnt arrange themselves, that was just too bad, she said. She had used all of her sick leave, and she wondered how long it would be before she was let go. Each day, she felt steadily worse as evening drew near. Despite her lack of appetite, she was eating so much (Filling up the void, I guess) that shed gained about 10 pounds. Though she slept an extra hour or two each night, she felt constantly tired and listless. She spent much of her time crying or accusing herself of being a terrible mom. Her own divorce several years earlier had been all my fault. She told her doctor that she felt worthless and had accomplished nothing with her life. Alice had recently thought about driving her car off the mountainside road near her home. However, she perked up and felt almost normal whenever her best friend, Marge, dropped in.

Symptoms of atypical depression

Here are the symptoms that differentiate typical from atypical depressions: The typical depressed patient has a poor appetite and loses weight, but Alice ate so much that she gained weight. The typical depressed patient complains of insomnia, but Alice slept more than usual. Depressed teenagers and young adults often have hypersomnia. If something good happens, depressed people typically dont feel much better, but in Marges company, Alice felt almost normal. Some patients with atypical symptoms also notice that their extremities feel heavy, as if weights were tied to them. Even when they arent depressed, these people may be unusually sensitive to rejection.

Treating atypical depression

As with other types of major depressive disorder, atypical depression responds rapidly to appropriate therapy; even untreated, they eventually remit. Two of Alices depressive symptoms were alarming: increasing feelings of guilt (she recognized that these were exaggerated, so she wasnt psychotic) and thoughts about driving off a cliff. Although she still went to work, she didnt function well there. These symptoms spelled a moderately severe depression, so she was offered medication, psychotherapy and social supportsthe classic biopsychosocial approach to psychiatric management.

Depression Alice was immediately referred to a psychologist to begin CBT. Her doctor started her on 20 mg/day of the SSRI sertraline. After 2 weeks, she had improved a little, so it was increased to 40 mg. Two weeks later, still stalled at slightly improved, she stopped sertraline. For a 2-week washout period she took no medicine at all. The ongoing CBT helped her through the transition. Then she began the monoamine oxidase inhibitor (MAOI) phenelzine (Nardil), with instructions to follow the special diet carefully. Until her mood disorder improved, she needed help with child care, so a social worker was asked to explore the possibility that her husband might take the children for a few weeks. (Had that not worked out, family services should be involved, through her county health department or perhaps a religious organization. Marge might also be a resource.) A month later Alice cheerfully reported that she felt lots better and was back at work arranging flowers.

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As in the case of Alice, the MAOIs often work better in atypical depressions than do some of the other antidepressants. However, it is usual to try one of the SSRIs first, partly because they often work well, partly because clinicians like to avoid the worry of a low tyramine diet.

Psychotic Depression
About 15% of people with major depression lose touch with reality. They may imagine they hear the voices of dead people or become deluded that they have died or are being persecuted. These obviously psychotic symptoms seem all too real to these patients, who sometimes react impulsively to them. Immediate action may be necessary to prevent destructive behaviors, including suicide. Brians wife, Joyce, worked quickly when she found him cleaning the shotgun he hadnt picked up in years. For weeks, Joyce had been trying unsuccessfully to persuade her 55year-old husband to see a therapist. Nearly 3 months earlier, Brians mood had darkened and the chores on his almond farm seemed a burden. Mornings were worstAnother damn day to get through, he would mutter on his way outdoors. Joyce couldnt even get him to eat his favorite foods, and she looked on in dismay as he buckled his belt a couple of notches smaller. Although he complained of feeling tired all the time, he would awaken at 2 or 3 in the morning. When Joyce was awakened by his tossing and turning and asked what was wrong, he would say he was worried about being in debt. Of course, we always have a few hundred dollars on our VISA card, Joyce later explained, but we pay it off every month. We own the farm, and theres my paycheck. But Brian insists were povertystricken, that well have to sell out. As time passed, Brian spoke less and less. When he did talk, he apologized for all the pain he had causedJoyce had no idea what he was referring to. Then he began to ruminate about his health. He thought he was going to have a stroke, that his heart would stop. Joyce described how hed get up, feel his pulse, pace around the room, lie down, put his feet up above his head, do whatever he could to keep his heart going. Hed ask to have his blood pressure taken several times an hour. I pointed out that hed had a checkup last month, but it made no difference. When Brian brought out the shotgun, Joyce called the doctor, who admitted him to a closed psychiatric ward. By this time, he was barely moving and speaking so slowly that it could take minutes to convey a single thought. When asked whether he planned to use his shotgun on himself, he slowly nodded his head.

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Symptoms and diagnosis of psychotic depression

The symptoms of psychotic depression are drawn from the same list as any other DSM-IV depression, but their number and intensity are more severe. Brians basic depressive symptoms included loss of pleasure in his usual activities and undeserved feelings of guilt. He felt worst in the morning, his activity level was severely slowed, and he slept poorly and experienced profound loss of appetite and weight. By the time he was admitted, he had become suicidal and evidently had a plan. His delusions were striking. Despite good physical and financial health, he remained convinced that he was poverty-stricken and about to have a stroke or heart attack.

Treating psychotic depression

Depressive delusions and hallucinations are not some separate disease but symptoms that require special treatment. Patients with psychotic depression often receive a combination of an antidepressant plus one of the newer antipsychotic medications such as olanzapine. The antidepressant will usually also be a newer one, such as an SSRI, but TCAs sometimes work better. However, the side effects and toxicity of TCAs make them more dangerous, especially for a patient who is psychotic or suicidal. Many patients with a severe depression respond best to electroconvulsive therapy (ECT), with its twin advantages of high effectiveness (about 80% respond well) and zero chance of a suicidal overdose. That was what Brians doctor recommended for him; three weeks later, he went home, recovered. For a severe depression, the safest place to be treated may be on an inpatient unitanyone whose depression involves delusions or hallucinations is too unpredictable to be safely kept at home, even if accompanied around the clock by watchful, caring adults. Suicidal ideas also suggest hospitalization, especially if theres a plan and a means ready to hand. If hospitalization isnt feasible, office visits as frequently as several times a week and interspersed with telephone calls, may serve as a (risky) substitute. In such a case, patient and family alike should be carefully apprised of the risks. Suicide plans, severe guilt feelings, marked loss of weight, or other especially grave symptoms should prompt a full psychiatric evaluation, with even the possibility of brief commitment, until safety can be assured.

Recurrent Depression
About a third of patients with major depressive disorder will have just one episodethats plenty, they will assure you. However, the rest will have repeated episodes, sometimes recurring for many years. Once recognized, the problem of multiple depressive episodes is usually managed readily

Symptoms and diagnosis of recurrent depression

This will be quick. The list of symptoms is the same as for any other episode of major depressive disorder, though they are often severe (profound guilt, suicidal ideas). Most patients recover completely between episodes.

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Preventing recurrent depression

Treatment of an individual episode of recurrent depression is as for any depressive episode (p 38). Then consideration turns to prevention of future episodes, using medications or specific psychotherapy such as CBT. The following factors can help you decide whether to recommend protection against further episodes. The symptoms were especially severe, e.g. psychosis or suicidal ideas. There have been multiple episodes. Two or more previous episodes predict greater likelihood of future ones. Episodes occur every 23 years, sometimes even more often. Without prophylaxis, such patients sometimes spend nearly half their lives fighting depression. The episodes are especially long-lasting or difficult to control. The persons life was badly disrupteddivorce, job loss, self-injury can result from even moderately severe depressions. There is a family history of bipolar disorder, which suggests risk for future episodes of both mania and depression.

Prophylactic treatment often means continuing the same treatment that was effective in the first place. If the treatment is psychotherapy, it could be gradually reduced in frequency, perhaps to once every 34 weeks. If medication, it should probably be continued at the same dose (lower doses will often allow breakthrough depression), though clinician appointments can usually be reduced as low as every 23 months. A family history of bipolar disease would encourage the use of a mood stabilizer such as divalproex or lithium. A pregnant patient who previously had a postpartum depression might want to start psychotherapy at once or take medication after she delivers. Even with long-term protection, some patients experience breakthrough symptoms. Then, youll need to increase the frequency or dose of the current therapy. Sometimes, it is necessary to take further measures yet, as discussed under treatment-resistant depression (below). With the patients consent, fully inform family and close friends about the mood disorder and the symptoms of recurrence to watch for. Some patients dont realize when they are becoming ill; their close associates are often in a better position to recognize the recurrent symptoms. Such an early warning network of family and friends can help ensure the ready availability of treatment. Many patients ask, Will I need treatment forever? A good answer is that forever is a long time, and most depressions dont require treatment nearly that long. Patients who have had frequent or severe recurrences will probably agree that long-term treatment is a breeze compared to the whirlwind of endlessly recurring depressive disease. For those who elect to discontinue maintenance therapy, taper them off treatment slowly enough that any symptoms of returning depression can be caught and remedied before they become disabling.

Dysthymic Disorder
People with dysthymic disorder (often shortened to dysthymia) feel depressed most of the time, but their symptoms are fewer and milder than in major depression. They are neither psychotic nor suicidal, but their mood is nevertheless low enough to cause interpersonal or work-related problems. Many people feel this way chronically, perhaps since adolescence (Ive always been

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depressed). They can go for years without realizing that persistent low mood isnt normal, and seek help only when, as often happens, they finally develop a major depression. Once the major depression departs, they usually return to their normal dysthymiaunless it is recognized and treated. Despite his years-long marriage to Carol, Ira admitted that he had always felt lonely and isolated. Ive never been self-confident, but she sure hasnt helped matters any. According to her, Ive never done anything right with the kidscouldnt even change a diaper properly. It seemed easier just not to be involved. He had always felt inferior to others; any form of rejection could devastate him for days. Carol added that he was reluctant to make decisions and that he always complained of feeling tired. His sleep and appetite had always been adequate and he never had suicidal ideas. Ive never been worse, but Ive never been much better, either. It didnt even make much difference when I won ten grand in the lottery. He discovered his dysthymia when they sought marriage counseling. I knew he was a quiet, private sort of person, even before we got married, Carol explained. But he wont even go on vacations with us. Most of the time, I feel like a single parent.

Symptoms and diagnosis of dysthymia

Because the symptoms of dysthymia can seem to merge with a persons character structure, recognizing it may be a problemIras symptoms seemed normal to him. Iras low self-esteem, difficulty making decisions, and gloomy demeanor are typical depressive symptoms, but he had too few of them for major depressive disorder. Also, they had lasted far longer than most major depressions. Without marriage counseling, he might never have been evaluated or received appropriate treatment. Major depressive disorder superimposed on dysthymia is sometimes called double depression.

Treating dysthymia
Dysthymia patients are often started on an SSRI. If that proves ineffective, a rational next choice would be just about any other antidepressant, including MAOIs. As with major depression, specific psychotherapy (CBT or interpersonal psychotherapy) can often either supplement or replace medication. Prolonged treatment may be needed to preserve improvement in this often chronic condition. Regardless of the specific treatment, unlooked-for consequences can occur. Successful treatment can change the way people feel about themselves. Within 2 weeks, Ira had improved to the point that he tried to take charge of all the family decisions. It quickly became apparent that he needed psychological help in adjusting to his newfound confidence. He and Carol continued their couple therapy, which eventually helped the family learn to live in a relationship where no one was depressed, passive, or dependent. As depressions go, dysthymia isnt dramatic. Perhaps that explains why it often goes unrecognized and undertreated, despite affecting about 3% of adults.

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Depression Due to Medical Illness or Substance Use

Many medical conditions can cause symptoms similar to major depression. These include such common disorders as thyroid disease, menopause, migraine, premenstrual syndrome, sleep apnea, and stroke. Depression occurs in Sjgrens, where it frequently begins before the typical physical symptoms of the syndrome. Some verge on the exotictick-borne Lyme disease, for example. It is unusual for these conditions to cause depression, and thats exactly what makes them dangerousif they routinely produced depression, wed consider them first with every patient we see. Unhappily, often its only when antidepressants and psychotherapy dont work or when more obvious symptoms of the medical condition appear that we twig the correct diagnosis. On the other hand, depression due to substance abuse is probably a lot more common than most people realize. Alcohol-related disease may cause more depression than all other drugs combined, but barbiturates, cocaine, heroin, or even nicotine withdrawal is occasionally the culprit. Most depressions caused by medical disease or by substance use dont need specific treatment, but they do require special care with diagnosis. Thats why physicians must ask questions to dredge up all the facts about their patients social and medical backgrounds; something as covert as closet drinking or as small as a tick bite could provide the clue to the right diagnosis. Post-partum depression A special kind of medically related depression develops in 10 15% of women within a few months of giving birth. The symptoms, often indistinguishable from major depression, appear related to rapidly falling hormone levels that occur after the expulsion of the placenta. Estrogens, taken either orally or by transdermal patch, can sometimes relieve depressive symptoms, but also pursue standard antidepressant measures. Dont confuse this depressive syndrome with the milderand far more commonbaby blues, which develops within the first few days after giving birth and remits spontaneously within a week or 10 days.

Situational Depression and Adjustment Disorder

Is depression ever normal? Of course, it seems natural to feel sad about any bad outcomea promotion lost or a romance gone awry. As the months drag by, someone who has lost a job and cant find another might feel increasingly dejected; its a frightening and lonely feeling not to be able to provide for your family. After 6 months of rejection, you might feel unable to go on pounding the pavement, looking for work. Heres the sort of situation thats ready-made for the term Adjustment Disorder with Depressive Featuresin effect, a depression thats sort of normal. Adjustment disorders (including subtypes with various featuresdepression, anxiety, mixed anxiety and depression, disturbed conduct, mixed disturbance of emotions and conduct, and unspecified) are diagnosed so commonly they constituted up to 1030% of mental health outpatient clinic populations. They occur at all ages, but adult women may be twice as likely as men to be so diagnosed. One problem with the concept is that very few really well-diagnosed patient cohorts have been followed up to determine whether this diagnosis was warranted in the first place. The line between clinical and understandable depression isnt always clear-cut. Although we might think that the sole cause of such a depression was job loss, we could discover that the

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patients parent had repeatedly been hospitalized for depression, suggesting that genetics accounted for part of the cause. When an antidepressant provided effective treatment, biochemical factors would seem implicated, too. Certain of the criteria make adjustment disorder a fraught concept. On the one hand, there must be an evident cause; on the other hand, you cant have confidence in the diagnosis until the cause departs and the depression retreats. The trouble for clinicians lies in discriminating cause from coincidence during the episode. It all comes down to this: Adjustment disorder is a nonspecific diagnosis that hasnt been especially well studied for which there isnt any specific treatmentother than allowing time to pass. It is a type of depression (or anxiety disorder) that should be placed pretty close to the bottom of anyones differential diagnosis. Bereavement Here is another syndrome that fits into the general area of depression due to an external event. Most people who have suffered the death of someone they love feel terribly sad, but the majority never require mental health treatment. Acute grief runs its course as those left behind adapt to their new circumstances and resume normal life, sometimes assisted by friends or groups such as the AARP Widowed Persons Service. Only about a third develop many symptoms of major depression. If depression lasts past 23 months, most clinicians would then treat for major depression, perhaps emphasizing a specific psychotherapy such as CBT.

Treatment-resistant Depression
Treatment-resistant doesnt mean a distinct type of depression; its just one that treatment appears not to alleviate. Appears, because the two biggest causes of treatment resistance have nothing to do with the effectiveness of medication or psychotherapy. Most resistance is caused by treatment that either is inadequate or is prescribed for the wrong diagnosis. A few years back I ran into Jon, a friend of many years, who seemed a little sadder than usual. I finally went to see about my mood, he said, and my GP started me on Prozac. It really seemed like it was going to help, I felt so much better. Why is that a problem? I wanted to know. Its stopped working. Im back to the way I used to feel, though Im still taking the same dose10 mg. Now, Jons about my height, but he must weigh twice what I do, so I told him that 10 mg seemed a modest dose for any adult; maybe he should ask his doctor about taking more. A few weeks later, Jon had doubled the dose and was feeling great. And hes been fine ever since. Jon was getting the right medicine but at the wrong dosehis doctor was too cautious by half. No medication can work well on a dose too small, and the same might be said for someone who is being seen in psychotherapy too infrequently or by the wrong therapist. Jons situation was easily diagnosed in a few minutes of casual conversation, but not all resistant depressions yield so readily. For several months, Earl had been treated for depression. His partners in an accountancy firm had voted him out for erratic behavior. After he and his wife separated, he began treatment with a clinician who first tried antidepressants, then a mood stabilizer. Nothing worked.

Depression A consultant reviewed his history for something his clinicians were missing, and came up dry. Then one evening his wife called and said that he was sounding very depressed. I know its unusual any more, she said, but could you make a house call? When the consultant arrived, Earl was lying on his bed, propped up on pillows with a bottle of whiskey in one hand and his 12-gauge shotgun in the other. Though the gun was pointed at the consultant, it seemed intended for Earl himself. Clearly, he had been less than candid about his drinking. Several months, some disulfiram (Antabuse) and a generous helping of Alcoholics Anonymous later, he was sober and no longer depressed.

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Drugs and other physical methods of treatment are just plain wrong for some depressions. Earls treatment resistance was due to a mistaken diagnosis that directed his clinicians attention away from management of his drinking problem. Similar stories can be told about patients with other diagnoses, including eating and personality disorders. Still, many patients with well-diagnosed depression respond poorly to the usual treatments. For them, consider these points: Is the dose high enough? If several weeks have yielded little or no effect from an antidepressant, an increased dose of the same medication may be the best next step, especially if there are few side effects. If psychotherapy every 2 weeks isnt helping, perhaps weekly sessions will work better. Has treatment been given long enough? Antidepressants can require 68 weeks for full effect, but 23 weeks should produce a glimmer of change. A month on a normally adequate dose with no change at all probably means its time to try a different antidepressant. Because clinical depression comprises a number of illnesses, and because each human being has individual chemical makeup and metabolism, some patients who dont respond well to one treatment may improve with another. Although professional opinions vary, if a patient hasnt done well on the first drug of choice, a change to a drug in a different class of antidepressants may be the next logical step. Add psychotherapy, increase its frequency, or change its focus or type. If the patient isnt using CBT or interpersonal psychotherapy, strongly consider one of these modalities. Blood level checks can sometimes help with certain classes of medication, such as the TCAs. Individual metabolism or other factors may be reducing the effective amount of available medication. Try an MAOIthey sometimes work when nothing else does. Consider ECT. Although some people hate the thought, it remains the most effective treatment option we have for severe depression. We sometimes think we understand why older people are depressedtheyve experienced so many lossesand overlook a treatable depression. For a depressed older patient, consider psychotherapy or smaller doses of standard medications.

Beyond this point, resistant depressions usually get treated with increasingly complicated drug combinations. For example, you can augment an antidepressant that has helped some by adding another drug, a strategy far more efficient, and possibly safer, than repeatedly stopping and starting antidepressants. An antidepressant plus lithium is one of the most effective combinations. Other drugs you can add include another mood stabilizer, thyroid hormone, or a central nervous system stimulant such as dextroamphetamine. You could also combine nortriptyline or desipramine with an SSRI such as citalopram.

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Sidebar: Suicide and Mental Illness

The low base rate of suicide (about 1% of the general population) and the inexact nature of the science make it hard to predict which individuals will attempt suicide and which will succeed. We have to rely on the seemingly numberless studies that try to pinpoint characteristics of suicide risk. Jay had retired after 30 years of honorable service in the Marine Corps. For a time hed worked in his brothers machine shop, but now he mostly just sat at home. A couple of years earlier, his wife had died. Theyd been childless, and he had never been a particularly social person. Now, in his late 60s, he lived alone on his military pension and Social Security. No one had heard much from Jay until he was brought to the emergency department after he attempted suicide by carbon monoxide poisoning. He had been discovered unconscious in his garage when a neighbor returned home unexpectedly at lunchtime and heard the purring of an engine. After several touch-and-go hours in intensive care, Jay recovered enough to speak with a mental health consultant, who learned that he had been drinking heavily to combat a severe melancholia. Jay was sallow and gaunt. His clothes hung on his 6-foot framehe had lost 20 pounds or more. He said that when he awakened about 3 or 4 each morning, he would lie there and brood about the death of a friend with whom he served in Vietnam. I could have picked up that grenade and heaved it, but I just jumped behind some sandbags. He had lost his interest in hunting, but he still kept two rifles and a pistol locked in a cabinet. He had smoked all his adult life; a doctor had recently told him that a spot on his lung was suspicious, and that he needed to come in for more tests. Not a religious man, he said that if he learned he had cancer, he wouldnt have it treated, though his father had died a horrible, lingering death from lung cancer. Jay would either move to Oregon and request physician-assisted suicide, or just do the job myself, in the comfort of my own living room. From the available information, Jays physician felt that there was an extremely high risk of further suicide attempts and placed him on a one-to-one suicide watch. That evening about 10, Jay went into the toilet and closed the door. Five minutes later, the aide attending him called out, and the staff broke down the door. They found him, nearly lifeless, hanging from a loop of bath towel and cut him down. There are two basic sets of risk factors for suicide: those that pertain to mental illness, and those that pertain to the individual.

Mental disorders and suicide

Like Jay, the vast majority of those who attempt or complete suicide have a diagnosable mental illness. Although suicide and suicide attempts are not tied to any one diagnosis, each of the following is associated with suicide behaviors. Mood disorders. Major depression and bipolar disorders account for about half of all suicides, mostly because patients havent been treated adequately for depression. Risk of suicide increases with more severe depression and with the presence of melancholic features (loss of pleasure in usual activities, feeling worse in the mornings, insomnia typified by awakening too early in the

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morning, loss of appetite or weight, excessive guilt, and a quality of mood that is more profound that typical grief). Recent studies have reported that in either depression or bipolar disorders, treatment with antidepressants or lithium decreases suicide risk. Schizophrenia. About 10% of schizophrenia patients die by suicide, usually in the first few years of illness. Risk is higher in those with paranoia or depressive symptoms, and lower in those with negative symptoms (flat affect, poverty of speech, inability to initiate action). In a person who has made previous attempts, command auditory hallucinations increase risk for another. Substance use. Patients with any type of substance dependence have a risk of suicide 23 times that of the general population (in those with heroin dependence, it is least 14 times greater). For patients with alcoholism, loss of a close relationship through divorce, separation, death, or interpersonal friction is a common precipitant; recent and heavy drinking increases the risk further still. Personality disorder. The risk of suicide is especially great in antisocial and borderline personality disorders. Others. Illnesses as different as PTSD and attention deficit/hyperactivity disorder may also confer an increased risk for suicide. There is even a risk with panic disorder, especially if major depressive disorder or substance use is also involved. Patients with somatization disorder often attempt suicide; although there are few data, I believe that these people also carry an increased risk for completed suicide. And please note that having more than one mental disorder greatly increases the risk of attempts and completed suicide.

Individual factors in suicide

For many years, numerous social and personal characteristics have been known to signal the risk of suicide: Male gender. Men are four times as likely as women to complete suicide, whereas women are three times as likely to attempt it. Advancing age. Suicide rates rise throughout the lifespan to peak in the over-85 group. Race. Whites are far more likely to commit suicide than are people of other races. Employment. Unemployed and retired persons, and those with long absences from work, may suffer from lower self-esteem and reduced access to support networks, both of which may increase risk. Marital status. Being single or divorced is a risk factor (divorced is worse); married people are less likely to commit suicide. Religion. The risk for Protestants is higher than that for Catholics and Jews. Risk for Muslims is unclear. Family history. Suicide in a relative increases individual risk, even beyond the presence of mental disorder. Living alone. Isolation often breeds despair. Access to guns and other lethal means. And dont forget medications that can be lethal in overdose. Physical disease. The burden of obstructive lung disease, cancer, epilepsy, chronic pain, and a host of other debilitating conditions predisposes patients to suicide; multiple illnesses greatly increase the risk. Feelings of hopelessness. An unrelieved gloomy view of the future especially predicts future suicide. Recent mental hospitalization. The first few days after discharge are the most dangerous.

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Financial difficulty. The image of stock market investors leaping from windows during the Great Depression of the 1930s was no mirage: The national suicide rate surged by 20%. Heavy gambling losses. Pathological gambling as such may not predispose; depression may mediate this factor. Talking about suicide. The saying Those who talk about it dont do it is exactly the opposite of fact: Most people who kill themselves have recently communicated their intent, often to a care provider. Suicide of others. The death by suicide of a friend, relative, or even a total stranger can increase the riskespecially in adolescents, for whom the pull of group behavior is especially powerful. Prior suicide attempt. After an attempted suicide, risk for completion persists for at least four decades. In one study, of those who made a medically serious suicide attempt, 9% had died within 5 years, over half by suicide. When evaluating an attempt, it is important to consider both medical and psychological seriousness. A medically serious attempt is one that causes unconsciousness, significant loss of blood, or disruption of parts of the body beneath the skin (tendons and arteries are examples). Psychologically serious attempts are those in which the patient expresses regret at surviving, has made efforts to avoid discovery, or states a determination to make another attempt. An attempt that entails either type of seriousness should put you especially on guard.

Review
Just out of college, Carl had taken a job at a large chain bookstore in the city. I always told myself, it was temporary, Carl reported. I suppose I should have gone out at gotten myself a higher status, better-paying job, like my college roommates did, but I just never felt that confident. Carl admitted that hed always felt unsure of himself, rather lowspirited, to tell the truth. Its normal for melike being tired, which has been the case ever since high school. He never had a lot of outside interests, and it had always been hard for him to focus his attention. Its just hopeless, he complained to Francine, his girl friend. Im in a terrible rut. By the time 5 years had passed and hed worked his way up to assistant manager, the rut had deepened. For weeks now he had barely managed to drag himself in to work, and he stopped participating in classroom discussions at the extension course he was taking in early American literature. With frequent awakenings throughout the night, sleep had become a horror. He didnt feel much pleasure, even when he was having sex (It was ok, but as in just about everything else, I felt that I performed horribly.) His girl friend, Francine, had become concerned at how much weight he had lost, finally demanded that he seek a medical evaluation. 1. 2. 3. 4. 5. Write out a complete differential diagnosis for Carl. [p 35] What would be your best diagnosis for Carl at the end of the first paragraph? [p 45] What important additional information about Carl do you need for a firm diagnosis? [p 33] Pick out Carls symptoms of a major depressive episode. [p 33] Outline your suggested treatment approach for Carl. [p 38]

Depression 6. If Carl had had an increased appetite and slept much longer than usual at night, how would this change your evaluation? [p 42] 7. How might your treatment change if Carl spoke of being punished for his sins? [p 43] 8. Review the history of Jay (p 50). Which risk factors for suicide did he have? [p 51

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Further Learning
A lot of memoirs discuss depressive disease and its consequences. Besides those Ive listed in the next chapter, which mainly concern bipolar disorder, I particularly like these two: The Bell Jar, by Sylvia Plath. It is beautifully written and contains enough detail that you can begin to understand how depression appears to sufferers. Are You There Alone? is Suzanne OMalleys careful laying out of the Andrea Yates story. Yates is the Texas woman who, in the midst of a psychotic postpartum depression, methodically drowned her five children in a tub of bathwater. She was subsequently found guilty of murder and barely escaped a sentence of death by a Texas court. The details provide plenty of opportunity for discriminating types of psychosis, and schizophrenia from mood disorder.

Chapter 4

Mania and Mood Swings

Brie danced into the interview room. With a pirouette and an attempted grand pli, she alighted in a chair and at once began to speak. Im delirious with joy, she volunteered. I just feel so lucky to have a great job, a great family, a great body. She swept a hand along the bulge of her side. So I went swimming in the fountain. She stood up and began to remove her shirt to show how she had stripped to go swimming the day of her admission. Ive never felt better in my life. When a nurse restrained her from disrobing, she looked downcast for a moment, but then started talking again. Brie had never before been admitted to a hospital. In fact, until the last 3 weeks her life had seemed ordinary. She spent far more time working than her job (she served as office manager for a state-wide polling organization) nominally required; recently she had begun to volunteer at an animal shelter. Luckily, I dont need much sleep. Just a couple of hours is plenty. Brie had spent part of her extra time on shopping. Two days before she was admitted, she bought ten dozen Bic pens. Ive got to have one for work, she said, and Im always losing mine. One morning, police were called to her place of work when two of her workers overheard her dialing numbers at random and asking unauthorized, intimate questions, such as what kind of underwear people were wearing. When she refused to stop, police were called. When she began screaming and threw several telephones at them, they decided she needed evaluation and brought her to the psychiatric emergency room. As she was helped into the back seat of their cruiser, she was saying, You think I need evaluation? You must be nuts! Throughout her interview, Brie maintained eye contact; her affect was buoyant and she often laughed and chatted, asking questions of several of the students. Several times, she arose to act out a part of her story. At one point, bending down to remove her sock so she could show off her painted toenails and fresh tattoo, she noticed an empty soda can on the floor under the table; she picked it up and began to speak about it, losing the thread of the previous conversation. She was talkative and hard to interrupt, and her speech included many unnecessary details that got her off track. At one point she said, And so I ended up

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Mania on a psychiatry ward. Hi, psych ward! [Looking around the room] Any other Wards here? My dads name was Edward. Edward the Confessor. Me, I confess, Im only Princess Di.

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Symptoms of mania
People whose mood is the opposite of depressed are said to have an episode of mania, which affects about 2 of every 100 adults. Mania is a description, not a diagnosis. For a patient with features of mania, any of several diagnoses are possible. Well cover them later in this chapter, but first, lets identify the symptoms. Of the 8 core symptoms listed in boldface below, it takes 4, including mood change, to qualify for a DSM-IV episode of mania. In Bries story, we can identify the symptoms typical of classic mania. Mood. Brie said she had never felt better, a self-assessment typical of people in full manic flight. Mood will usually appear to be highexcited, euphoric, or excessively joyful. If only moderately elevated, the mood can be quite infectious: when we are around someone who is manic, as long as that person isnt too high, we feel good and want to laugh. However, some mania patients arent so much euphoric as cross or irritable; they can feel pretty uncomfortable when they are manic. They quarrel and argue with their friends and relatives, and they can progress to downright hostilityespecially if they are thwarted or feel threatened. In the later, more severe stages, even the mood of euphoria can have a perceived driven and unpleasant quality. For some patients, moods shift rapidly, even minute to minute; during the course of full mania, someone may suddenly become quiet, subdued, even tearful for a few moments before once again shifting into high. Increased activity level. Fairly bursting with energy, Brie had trouble sitting still. For a mania patient, everything tends to be speeded upthey move fast and seem forever busy. Though their activities are generally goal-directed, they may be interested in everything and tend to make many plans, often starting projects they will never finish. Talkativeness. Mania patients talk a great deal, about nearly anything, perhaps for hours on end, sometimes whether or not anyone is listening. (Brie started talking without prompting.) Speech is rapid, often loud, and imbued with a driven quality that we call pressured speech. Patients can become so difficult to interrupt that they dont really converse, but lecture. Racing thoughts. Mania patients entertain so many thoughts that even rapid speech cannot keep up as they jump from one idea to anothera form of thought disorder called flight of ideas. Bries last speech provides an example. Distractibility. Small diversionsnoises in the hallway, a fly on a window sill, a cola can under a tablecan divert the stream of thought into a different channel. Reduced need for sleep. Brie slept less than usual, and she was glad. Typically, mania patients dont describe insomnia as a problemwhy sleep when there is so much to be done? Inflated self-esteem. During mania, people typically feel important and overconfident, describe their accomplishments in glowing terms, and ignore their failings. Bries comment about her great body suggests inordinate feelings of self-worth. Faulty judgment. Brie impulsively bought pens she didnt need and disrobed in public; other mania patients spend thousands they cannot afford, sign contracts they cant fulfill, have sexual indiscretions. Their actionswhether gambling, drinking, using drugs, or violating professional ethics, such as having sex with patients or spending money entrusted to them by clientscan endanger themselves and those around them.

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Typically, patients with mania dont recognize that they are ill or even how their mood has changedbut those around them do. When you try to enlighten such patients, they dont believe you, in effect responding with complete lack of insight, How could I be sick?I feel terrific! They will refuse care and become angry, sometimes violent, if forced into treatment. (However, after the period of mania subsides, most express remorse for their former extravagant behavior.) If you havent experienced mania in a friend or relative, you can barely imagine the extent to which such symptoms can interfere with work (school) and produce financial turmoil, and problems in personal relationships. As the illness escalates, impulsivity and faltering judgment yield chaos. A breadwinner whose family needs require two jobs gives away $10 bills on the street; a mother of 3 young children books passage for Argentinaone way. Especially likely are sexual involvement, marital discord and divorce. With worsening illness, agitated hyperactivity, purposeful at first, gives way to pacing, even fighting. Associations may loosen to the point of clang associations or word salad; extreme cognitive disturbance can produce disorientation and confused behavior. Rarely, catatonic symptoms will ensue (manic stupor). Ultimately, lack of sleep may produce exhaustion that, if not remedied, can lead to collapse and, in extreme cases, death. Perhaps a third of mania patients become psychotica higher percentage than patients who have only depressions. Usually, psychotic symptoms begin as other mania symptoms escalate, but they sometimes appear early, during the first week or two of illness. Although some patients become hostile and paranoid, manic themes are usually grandiose (such as being on a secret government mission or having a relationship to divinity). Grandiose delusions tend to be congruent to the exalted mood. Patients may believe that they have super powers (they can change the weather) or that they are in fact celebrities or religious figures such as Jesus.

Differential diagnosis
As with any other psychiatric disorder, you cant make a diagnosis solely on the basis of the symptoms. The patient must also meet other conditions, outlined in Table 2 66. Well discuss each of the several psychiatric disorders that can present with symptoms of mania, beginning with the more common ones. But the differential diagnosis places them, as usual, in a rough order on the safety hierarchy. Mania due to substance use Mania due to a medical condition Bipolar I Bipolar II Cyclothymic disorder Schizoaffective disorder Schizophreniform disorder Normal?

Bipolar I Disorder
We used to call this more severe disorder manic-depressive disease, but most clinicians today use the term bipolar I. Thats the term clinicians use for patients like Brie who have at least one episode of full-blown mania and who fulfill a short list of other requirements: they have no substance use or apparent physical cause for mania, and the illness is serious enough to impair

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social, personal, or work functioning. Most such patients also have at least one lifetime major depressive episode. An occasional patient has had only manias, though most clinicians will tell you that, given enough time, nearly all manic patients will eventually have a depression. Some bipolar patients have mixed states, during which they experience a combination of manic and depressive symptoms. On average, bipolar I patients have 8-10 lifetime episodes, beginning in their late teens or early 20s and returning intermittently throughout life. However, a few patients will experience a first mania only after many years of repeated depressions. It sometimes takes years to get the diagnosis right. Remarkably, even with modern criteria and all the publicity bipolar disorders have received during the past 40 years, some patients are still misdiagnosed as having schizophrenia or some other psychosis.

Course of illness
Mania usually builds over a week or two (at least one week of symptoms is required for DSM-IV diagnosis). Because its social consequences are often dire, it is almost never left to run its natural courseperhaps 3 months of symptoms before it spontaneously resolves into either a depression or a normal mood. Even knowing nothing about an individuals actual symptoms, clinicians often strongly suspect bipolar I disorder based solely on a typical course of illnessepisodes of mania and depression with interspersed periods of normal mood. Although there may be long periods of normal mood, without treatment patients with bipolar disorder tend to cycle up and down for many years. Mistakes in diagnosis (many patients have been erroneously diagnosed with schizophrenia) probably occur less often now than they did half a century ago. The consequences of delay in treatment can be devastating in terms of anguish sustained, money spent, and even lives lost. Though acutely manic patients rarely kill themselves, once depression supervenes, suicide is a too-often tragic outcome.

Epidemiology and etiology

Like depression, bipolar disorder occurs somewhat more often in females than in malesthe ratio is about 3:2. Although the range is broad, on average it begins around age 25even earlier than major depression. When it begins in childhood, it tends to be seriously underdiagnosed. Men have a somewhat earlier onset than do women. It is no respecter of race, culture, or economic status. Genetics. Many studies find a high relative riskabout seven times that of the general population in relatives. That holds for both bipolar I and II in first-degree relatives of bipolar patients, whose relatives also have an elevated risk of unipolar depression. Having a parent or sibling who has had mania increases the individuals risk of bipolar disease to around 10%far greater than for the general population. For a depressed person who has a relative with mania, the risk of eventually developing mania or hypomania is substantial enough that family and friends should watch for symptoms of mania (or recurrent depression). A strong genetic component to bipolar disorder is demonstrated by these facts: (1) Monozygotic twins of bipolar patients are about 60% concordant; dizygotic twins 7% concordant; (2) Adoption studies find biological relatives are at greater risk for bipolar disorder than are adoptive relatives. Different studies of linkage have reported various putative chromosomal sites, but most of these studies have not been replicated.

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The tendency to bipolar disorder is probably caused by genes at three or more loci that interact to cause the disease. Maternal inheritance may be more common than paternal inheritancethe parent-of-origin effect. It has been explained by imprinting (alleles are expressed differently, depending on gender of affected parent); by mitochondrial inheritance, by X-Linkage, by the effect of being reared by a mother who is ill; or by intrauterine factors. Of course, family history isnt synonymous with heredity; with a concordance rate less that 100%, theres lots of room for environmental influence. Here are some of the other factors that have been implicated in the expression of bipolar disorder: Psychosocial stressors. These include events such as losing a job (or being hired), getting married (or divorced), trauma, illness, and a host of others. Note that it is hard to know where to draw the line between pathology and a normal reaction to lifes vicissitudes. It is harder yet with mania, and there is little evidence for precipitated mania. Stress may cause cortisol release in anyone, but it takes root in soil prepared by heredity. Anatomical structures. Some investigators have reported that subcortical structures such as the amygdala, hippocampus, and striatum are affected differently in bipolar and major depressive patients. Neurotransmitters. Increased norepinephrine (NE) turnover has been reported in cortical and thalamic areas; plasma NE and its major metabolite, 3-methoxy-4-hydroxyphenylglycol (MHPG) is lower in depressed bipolar than in depressed unipolar patients. CSF NE and MHPG are higher during mania than during depression. There are recent reports that low plasma tryptophan (precursor to serotonin) may cause unaffected relatives of bipolar patients to develop low mood and impulsivity. Dopamine agonists (such as pramipexole, used to treat parkinsonism) not only have an antidepressant effect but in some bipolar patients have precipitated mania. HPA axis. The increased hypothalamic-pituitary-adrenal axis activity reported during bipolar depression and mixed manic states has inconsistently been reported during mania. Sleep. For years we have assumed that mood disorders produced sleep disturbances. Now, some evidence suggests the oppositethat disrupted sleep can precipitate a manic episode. Further, bipolar patients with normal mood who continue to have insomnia may be at special risk for relapse.

Comorbidity
In addition to the mood swings, many bipolar patients also have other mental problems. The most common comorbid condition is substance abuse, especially alcoholism, both of which are especially likely when onset of the mood disorder is relatively early. Although Brie didnt drink, many mania patients do abuse alcohol. They may be trying to modify their own high moodsan acute mania is an uncomfortable mental state for many patients. Others may just be trying to enhance the high feeling. In any event, alcohol and other substance use can confuse the picture and even fool experienced clinicians. Other comorbid illnesses include eating disorders (both anorexia and bulimia nervosa) and anxiety disorders such as panic disorder and social phobia.

Treating mania
For decades, the powerful mood stabilizer lithium was the standard treatment for acute mania; for many patients it remains the treatment of choice. Divalproex (Depakote) works faster and has

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fewer side effects, but overall lithium provides the greatest degree of improvement for the most patients. For some patients, however, it isnt enough. Severe mania may require the addition of one of the newer antipsychotic medications such as olanzapine (Zyprexa)this will be especially true if the mania is accompanied by psychosis. A benzodiazepine such as clonazepam (Klonopin) or lorazepam (Ativan) may be added to manage the accompanying severe agitation, insomnia, and panic. Although older antipsychotics like chlorpromazine (Thorazine) and haloperidol (Haldol) used to be popular, their potential for serious side effects has relegated them to a backup role. Rarely, mania doesnt respond adequately to any medication; then ECT will often normalize mood. A patient who responds inadequately to lithium or other first-line treatment may need a concurrent mood stabilizer, such as divalproex (Depakote) or carbamazepine (Tegretol). If that still doesnt work, a different mood stabilizer such as lamotrigine (Lamictal) could be tried. For a mixed episode, divalproex may work better than lithium. Bipolar I patients who dont get effective treatment can lose months or years of normal life. About half of those with bipolar illness can be treated as outpatients, but the rest have manias that often require hospitalization to prevent harm coming to them and others.

Preventing future episodes

Without adequate prophylaxis, relapse is likely within six months of a manic episode. Therefore, patients should be counseled to begin maintenance therapy immediately following a first manic episode. It is especially important to begin prophylactic medication early in the presence of rapid cycling, multiple episodes, or episodes that are especially severe, but maintenance treatment for bipolar II (which well define later) is also important. Usually, that will be simply the continuation of whatever mood stabilizer worked best for control of the acute episode. For someone with relatively few episodes of mania with euphoric (but not irritable) mood, history of mood disorder in relatives, and no current substance abuse, lithium remains the treatment of choice. However, it is less effective for patients who have had many prior episodes, who cycle rapidly, who function poorly between episodes, who also have a personality disorder, or who abuse alcohol or street drugs. If any of those factors is present, divalproex or carbamazepine may be a better choice. Continuing concurrent use of antipsychotic medication doesnt appear to be generally helpful, and these drugs should be tapered as tolerated. For some patients, lithium becomes more effective with continuing use; for others, resistance to it develops after a time. There is also some evidence that stopping lithium for any reason can render it less effective when it is restarted. As with the acute management of mania, those who continue to have mood swings despite the foregoing measures can be helped with the newer mood stabilizing drugs such as lamotrigine. Beginning with fidelity to their treatment regimens, patients can do much to prevent further episodes of either mania or depression. Attending a mood disorders clinic every month or two can also help patients feel better about their illness and remind them of the problems they had when ill and help motivate them to stick with treatment. Also important is teaching patient and relatives about watching for stress or signs of recurrence, complying with treatment recommendations, and dealing with stress. Despite prophylaxis, some patients will continue to have low-grade symptoms or breakthrough mood episodes. If mania breaks through, taper off any antidepressants and check to see that the dose of maintenance medication, and serum drug level, is optimal. You may to add

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another mood stabilizer, an antipsychotic, or a benzodiazepine. Even maintenance ECT might be needed in rare cases.

The physicians approach to the patient

How best to approach the mania patient strongly depends on severity. Its relatively easy to talk with a hypomanic person, who can converse more or less normally, is amenable to persuasion, and can often be thoroughly enjoyable to be around. Dealing with more severely ill patients can be quite another matter; here are a few pointers: Because they tend to speak loudly and at great length, you may need to interrupt repeatedly just to ask basic questions. This should be done politely, if firmly, and whenever possible with humor. (Sheesh, Ive got to stick my oar in again and so forth). If at all possible, avoid confrontation. This strategy may work because of the storied brief attention span of maniaif you havent alienated the patient with previous confrontations, waiting a few minutes might just earn you another chance at promoting whatever attitude or action that was initially rejected. Responding loudly to a loud, talkative patient is an exercise in futility; instead, reduce the volume of your own voice when you speak. Most people, even mania patients, wont shout at someone who is speaking ever more softly. Try to find a lure to draw the patient into the treatment process. This might be most anything within reason the patient wants, perhaps a glass of water or speaking with a relative on the telephone. Then, While were arranging that, perhaps you could answer just these two questions When a patient simply refuses to cooperate, work with relatives, friends (and sometimes the legal system) to present a united front. Always consider safetyyours and the patients. Place yourself near an exit (never with the patient between you and escape); try to interview with a colleague present, or at least within earshot; and know how to activate your facilitys emergency call system. Finally, it is usually OK to laugh with, though of course never at, a mania patient. Indeed, it is sometimes difficult to avoid, inasmuch as these people are often (sometimes unintentionally) extremely funny. It can work well to hold your amusement and let it out once the patient laughs or tells a joke.

Treating bipolar depression

Although bipolar depressions are similar to those of major depressive disorder, a patient who has had an episode of mania and is now depressed will need treatment that differs from a nevermanic depressed person. Many antidepressants can precipitate an abrupt switch into mania, so they should never be used alone; a mood stabilizer (lithium, divalproex, lamotrigine) should be in place when an antidepressant is prescribed for a bipolar patient. Indeed, for some patients, mood stabilizers alone can produce a good antidepressant effect without risking a switch into mania. The risk of a switch into a high phase is less for bipolar II than bipolar I patients. For depressions that dont respond adequately to the mood stabilizer, augmentation sometimes works better than substitution. Try adding either a second mood stabilizer or thyroid hormone. When an antidepressant is necessary, bupropion (Wellbutrin) or an SSRI may minimize the risk of a switch to mania. Soon after the depression lifts, bipolar patients should try

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to taper off the antidepressant medicationwhile faithfully remaining on the mood stabilizer, of course. CBT can be useful, and has the added benefit of not provoking mania. Very recently, the wakefulness-promoting drug modafinil (Provigil) has been reported to improve symptoms of bipolar depressed patients who have not responded well to more conventional therapy.

Outcome of bipolar mood disorder

Once started on a mood stabilizer, many patients remain well for yearsas long as they continue taking medication. But at any given time, about a third of bipolar patients are not receiving the care they need. Some feel they dont need treatment between episodes, others dont think they are ill, even during an acute episode. But even with modern treatments and good compliance, some bipolar patients fare poorly; after a few months, the acute mania gradually disappears, to be replaced by chronic grandiose delusions. They become alienated from their families and, lacking even this support, become less and less likely to get competent mental health care.

Rapid Cycling
Although the average bipolar patient has fewer than a dozen lifetime episodes, about 20% cycle rapidly: in the course of a year they have four or more episodes of depression or maniaand some far exceed even this. It is especially common among women and those who have had several previous bipolar episodes. The pattern can take the form of alternating highs and lows or repeated brief mania or depression. Some patients recover for a time in between episodes, but others cycle more or less continuously. Although rapid cycling often resolves spontaneously within a year, it can be hard to treat. Although controlled evidence is lacking, traditional antidepressants have been linked to rapid cycling or causing a switch into mania, so they should be used with caution, if at all. Lithium may not adequately stabilize these patients, in which case divalproex or lamotrigine may prove a good choice, even for one of those rare individuals whose moods swing up or down every 48 hours. A combination of mood stabilizers may work when a single drug doesnt. Rapid cycling is especially likely to respond if there are atypical symptoms such as sleeping too much, increased appetite, or feeling worse in the evening.

Hypomania and Bipolar II

The upward mood swings some people experience never progress farther than moderate, in other words, an episode of hypomania. Although they may talk loudly (and a lot), their train of thought can be interrupted. Their activity level is heightened but generally goal-directed and (often) quite productive. They retain insight that something is different or wrong. They dont have hallucinations or delusions or require hospitalizationeither of these conditions would signal a full-blown mania. A patient with hypomania could have one of 3 different diagnoses: 1. Bipolar II disorder. This term means that the patient has had at least one major depression and at least one episode of hypomania, but never an episode of mania.

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2. Bipolar I disorder. The current episode is hypomania, but in the past the patient has had at least one manic episode. 3. Cyclothymic disorder. Well cover that one below. Taken together, the hypomanias of bipolar II and cyclothymic disorder are more common than bipolar I, Though their urgency is different, mania and hypomania are treated about the same. However, because they are less severely ill, people with hypomania sometimes dont bother seeking treatment. Instead, they react to mood swings by making changes in their lives such as moving, changing jobs, and falling in or out of love. If a major depressive episode develops and is treated, even clinicians may not recognize the need for mood stabilization because the patient seems only to have returned to normal.

Cyclothymic Disorder
Here you would never have severe depression but would alternate between mild episodes of depression and hypomania. Rather than incapacitating high phases and typical major depression, these patients chronically experience mild instability of mood. Their phases are continuous and may last weeks to months before switching into the opposite phase. For over 10 years, Holly had experienced mild mood swings once or twice a year. During her depressive phase, she was quietly unhappy and lethargic and irritated her relatives. After a reclusive few months, her mood would brighten; for the next several months, her energy and enthusiasm allowed her to accomplish a great deal (You can, when you get up at 4 A.M.). She would go to (and give) parties, and she wrote poetry. When her husband finally persuaded her to seek a mental health evaluation, she was astonished to learn that her condition was a disorder with a name. I never thought much about it, she commented. I always assumed it was just the way I was. Once lithium had stabilized her moods, for a time she thought of herself as productive but dull. Later, she discovered that her creativity was intact, only now tinged with discipline. Her daughters said that they could relate to her better, now that they no longer had to wonder where Mom would be from one day to the next. Once regarded as a disorder of personality, cyclothymia is now recognized as a part of the bipolar spectrum of mood disorders. Indeed, such patients can sometimes evolve into bipolar I or II disorder, and sometimes develop relatively mild mixed states.

Seasonal Affective Disorder

For some people, mood disorder assumes a peculiar patternthey become depressed in the fall or winter, returning to normal or even hypomanic in the spring or summer. In tropical regions, the pattern may be reversed. Seasonal affective disorder (SAD, sometimes referred to as seasonal mood disorder) is somewhat more likely to occur in the far north, but there may be a role for factors such as genetics and climate (heat and humidity in the tropics). Sal requested treatment for depression when he was a junior on a college athletic scholarship. Every autumn for 3 years, he had become depressed enough that his interest in school work and athletics waned. Because his appetite fell off, he had trouble maintaining

Mania his playing weight; he also complained of insomnia. I might as well be setting an alarm, he told the doctor. My eyes click open and there I am, worrying about the next game, or passing chemistry, or whatever. When spring came around, it was a different matter. He seemed to explode with enthusiasm when he went out for baseball. Batting .400, he played in every game. With loads of energy, he said he felt like another Babe Ruth.

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Sals fall-winter depression symptoms included insomnia, low mood, reduced appetite, loss of interest, and ruminations. Although he wasnt incapacitated throughout the autumn, compared to the spring his performance was minor league. Springtime hypomania is common, and full summer remission is the rule. Note that Sal wasnt delusionalhe said that he felt like Babe Ruth, not that he was the Bambino. The diagnosis of SAD has special implications for treatment. Although medications (especially the SSRIs) may help, for relatively mild cases bright light therapy (BLT) can work just as well with little risk of side effects. Often, it is the treatment to try first. This is what Sal did. For 90 minutes early each morning, he studied while he sat in front of a box that provided very bright light (10,000 lux). He began to improve within a few days, and after 10 days his interest in sports had returned and his sleep was normal. BLT has been demonstrated effective for other conditions than SADincluding premenstrual depression, the bingeing in bulimia nervosa, and improving sleep and reducing agitation in dementia patients. Some clinicians feel it can also work in depressed patients who do not have a seasonal pattern. BLT often works quickly, but sometimes several weeks are required for it take effect, so treatment should be started as soon as symptoms appear. Moderate to severe winter depressions may require a combination of BLT with an SSRI antidepressant. If the seasonal mood swings are especially severe, a mood stabilizer might be necessary to try to reduce the likelihood of future episodes.

Mood Swings Due to a Medical Disorder

A variety of medical diseases can cause manic-like symptoms. When he was 27 years old, George III, King of England during the American Revolution, became depressed. He was so melancholic that for several weeks he complained of fatigue and insomnia, and he lost weight. After a month or so, he recovered spontaneously and remained well for the next 23 years. At age 50, King George experienced his first psychosis. In the fall of that year he experienced severe abdominal pain and depression; suddenly, after 4 days, he became high-spirited and agitated. He spoke rapidly and at great length, his ideas jumping from one subject to another. At other times, his speech was incoherent. Hours of nonstop talking left him hoarse. He became so irritable and easily offended that his wife became alarmed and afraid of him. When he was finally forced into medical care, he became hyperactive and lost weight. At times abusive, he swore at those who tried to restrain him and even physically fought them; he refused his medication and threw them away. George slept little, had trouble concentrating, and often appeared worse in the evenings. He expressed the delusion that a deluge had submerged London; he ordered the royal yacht to rescue survivors. At times appearing depressed, he once begged his attendants to kill him.

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As depicted in the riveting 1994 film The Madness of King George, these symptoms sound like mania. However, Georges underlying condition was probably porphyria. Other medical conditions that can cause manic-like mood swings include AIDS, brain tumor, cerebrovascular accident, cryptococcosis, Cushings syndrome, epilepsy, head trauma, Huntingtons disease, multiple sclerosis, pernicious anemia and syphilis. Of course, treatment depends on the nature of the underlying disease; although most cases of mania are not due to an underlying medical disorder, any mood disorder patient should have a complete physical evaluation.

Substance-related Mood Swings

A variety of substances can produce euphoria and other disturbances of mood. Although the disinhibiting effects of alcohol are perhaps all too familiar, they last only until the individual sobers upan excellent demonstration of how important it is to pay attention to the longitudinal course of the patients history. History, careful observation for associated signs, and laboratory studies may identify other substance-related manic symptoms, including pressured speech, hyperactivity, and poor judgment, but the absence of longitudinal features such as recurrent episodes not related to substance misuse. In such instances, of course, treatment is wholly dependent on reigning in the substance use problem. Impaired judgment can result from the misuse of alcohol and just about any street drug. Euphoria may be noted during intoxication with cannabis, cocaine, amphetamines, and the opioids.

No Mental Disorder?
Some critics believe that psychiatrists diagnose bipolar disorder too frequently and prescribe mood stabilizers too freely. Mistakes in diagnosis can occur if a clinician thinks someone has an unstable mood due to bipolar disease, when it is really irritability brought on by drug use, personality disorder, even the ups and downs of normal adolescence. Limits on hospital stay or insurance reimbursement may encourage clinicians to come to closure too quickly. Then, mood stabilizers can end up being used to treat what could be mere moodiness. When in doubt as to the actual cause of moodiness, a daily charting of the ebb and flow of symptoms may help identify possible triggers, such as seasonality or distressing life events.

Review
[This case continues the vignette begun in the depression chapter review, page 52] After feeling like his old self for several days, Carls mood began to swing upwards. As he told his PCP later, First I felt contentment; then I felt exhilarated, like I could conquer the world. As his mood lifted, his horizons expanded, far beyond his bookstore job. First, he decided to open his own store; hed write his memoirs; then he might venture into publishing. He started a long to-do list of all the preparations he needed to make and, working late one night, wrote out the first seven chapters of his book. Once again he began seeking out his friends, sometimes calling them at all hours to chat (I just dont care that much for sleep, he later said). Now he talked more in class, nearly taking over control of the discussion. Several times his teacher had to ask him to be quiet. Finally, his girlfriend,

Mania Francine, persuaded him to return to his psychiatrist; after half an hour of discussion, he accepted a recommendation for treatment.

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1. Which symptoms/signs of a manic or hypomanic mood episode does Carl have? [p 55] 2. Which symptoms does he have (or lack) that spell the difference between hypomania and mania? [p 61] 3. Using the safety principle, construct a differential diagnosis for Carl. [p 56] 4. What is Carls most likely diagnosis? [p 56] 5. What symptoms define the difference between a diagnosis of bipolar II and bipolar I? [p 61] 6. How would Carls symptoms have to be different to qualify for a diagnosis of cyclothymic disorder? [p 62] 7. What acute treatment measures would you recommend for Carl? [p 58] 8. How would you counsel Carl as regards prophylactic management? [p 59] 9. What would you say to this family? [p 59]

Further Learning
For insight into the lives of patients who have immoderate mood swings, try either of these two books: A Mind That Found Itself, by Clifford Beers. Published in 1908, it is the classic biography of a person with bipolar disorder who was ill long before the modern era of medication began. Its free online from Project Gutenberg (http://www.gutenberg.org). An Unquiet Mind, by Kay Redfield Jamison (1995). A psychologist and professor of psychiatry at Johns Hopkins who has devoted her life to research and writing about bipolar disorder relates her own experiences with the illness in this riveting memoir. Its the best account we have of a bipolar patients inner life.

Mood disorder tables Table 1. Symptoms and other criteria of mood episodes.
Mood, duration For most of nearly every day for 2+ wks: Depressed mood or appears depressed to others; or Markedly decreased interest or pleasure in nearly all activities Symptoms 5+ of (mood or decreased interest must be included): Mood depressed or looks depressed Decreased interest or pleasure Change appetite or weight Change sleep Change psychomotor activity Fatigue Decreased self-worth Decreased concentration Death thoughts, suicidal ideas or att. 3+ of (4+ if mainly irritable): Grandiose or self-esteem Decreased need for sleep Increased talkativeness Racing thoughts Increased distractibility Increased psychomotor activity Poor judgment Severity Clinical distress or impaired work, social, personal functioning Exclusions Not GMC Not substance-related Not mixed episode Not within 2 months of bereavement (unless severe)

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Major depressive

Sustained high, expansive, or irritable mood for 1+ wks (if hospitalized, may be less) Sustained high, expansive, or irritable mood different from usual mood for 4+ days Mania and depression for 1+ wks

1+ of: Psychosis Hospitalized Impaired work, social, personal functioning A distinct change that others can recognize No psychosis Not hospitalized 1+ of: Psychosis; Hospitalized; Impaired work, social, personal functioning

Not GMC Not substance-related Not caused by somatic therapy* Not mixed episode Not GMC Not substance-related Not caused by somatic therapy* Not GMC Not substance-related Not caused by somatic therapy*

Hypomanic

Manic

Table 2. Combining mood episodes into mood disorders.

Mood episode Exclusions & Other Features No manic, mixed, hypomanic episode unless precipitated by somatic treatment for depression* Not better explained by schizoaffective; not superimposed on other psychosis Not GMC or substance-related Not better explained by schizoaffective; not superimposed on other psychosis Not GMC or substance-related Symptoms cause clinically important distress or impair work, social, or personal functioning No manic or mixed episodes Not better explained by schizoaffective; not superimposed on other psychosis Symptoms cause clinically important distress or impair work, social, or personal functioning Types of Pattern Single depression Recurrent depressions

Mixed

Meets full criteria for both manic and major depressive episodes

Major depressive disorder

1+ major depressive episode(s)

1 or more manic episode(s) May be major depressive episode 1+ major depressive episode(s) 1+ hypomanic episode(s)

Single manic episode Most recent episode manic Most recent episode hypomanic Most recent episode depressed Most recent episode unspecified

*Somatic therapy: medication, ECT, bright light Severely impaired functioning, severe preoccupation with worthlessness, ideas of suicide, delusions or hallucinations, or slowed

Bipolar II mood disorder

Bipolar I mood disorder

Mood disorder tables Table 3. Mood specifiers that apply to current or most recent mood episodes and to dysthymic disorder.
Description Criteria 2+ of: Increased appetite or weight Excessive sleeping Limbs feel heavy, leaden Work or personal relations impaired by sensitivity not limited to depressed periods Does not have melancholia or catatonia in same episode 2+of: Immobility or stupor Apparently purposeless hyperactivity not influenced by external stimuli Mutism or extreme negativism Prominent posturing, stereotypies, mannerisms or grimacing Echolalia or echopraxia 3+ of: Different quality of depressed mood from bereavement Consistently feels worse in the mornings Awakens at least 2 hrs early (terminal insomnia) Psychomotor activity markedly speeded up or slowed Marked loss of appetite and weight Excessive or inappropriate guilt feelings Can apply to: Major depression Dysthymia Bipolar I depressed Bipolar II depressed

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With atypical features

Mood reactivity, cheerful with good fortune, sad with disappointment

With catatonic features

Major depression Bipolar I depressed, manic, mixed Bipolar II depressed

With melancholic features

With major depressive episode, either or both: Loss of pleasure in nearly all activities; Feels no better when something good happens The episode occurs within 4 weeks of giving birth

Major depression Bipolar I depressed Bipolar II depressed

With postpartum onset

Major depression Bipolar I depressed, manic, mixed Bipolar II depressed

With/ without full interpisode recovery

Full remission between two most recent episodes

In past year, 4+ episodes

With rapid cycling

These patients meet criteria for major depressive, manic, mixed, or hypomanic episode. The boundaries of the episodes are indicated by a switch between high and low or by a 2+ month period of remission. Regular seasonal changes as described for 2 or more years. No nonseasonal major depressions during this time. Lifelong, seasonal major depressions materially outnumber nonseasonal episodes. Disregard episodes where there is a clear precipitant, such as being unemployed every summer.

Major depression regularly begins at a particular season of the year, as does full recovery or change of polarity.

With seasonal pattern

Mood disorder tables Table 4. Symptoms and criteria of other mood disorders,
Mood, duration Symptoms Hypomania when high; when depressed, does not meet criteria for major depression Severity Clinical distress or impaired work, social, personal functioning Exclusions Many periods of hypomania plus many periods of mild depression for 2 years; longest symptom-free period is 2 months Depressed, or appears depressed to others most of the day, most days for 2 years; longest symptom-free period is 2 months

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2+ of: Change in appetite (up or down) Change in sleep (up or down) Fatigue or low energy Poor self-image Indecisiveness or poor concentration Hopeless feelings

Dysthymic

Clinical distress or impaired work, social, personal functioning

Depressed or loss of interest or pleasure, or elevated, expansive, irritable Duration not specified Depressed or loss of interest or pleasure, or elevated, expansive, irritable Duration not specified Depressive symptoms begin within 3 months of stress; resolve <6 months after stressor ends Major depressive, mixed or manic episode; 1+ months continuously ill

History, physical exam or laboratory evidence that either: Symptoms developed within 1 month of intoxication or withdrawal, or Medication use caused symptoms History, physical exam or laboratory evidence suggest a GMC has caused symptoms.

Substance use

Clinical distress or impaired work, social, personal functioning

No manic, mixed, or major depressive episodes first 2 years; Not schizoaffective or other psychosis Not GMC, substancerelated No major depression 1st 2 yrs No manic, mixed, or hypomanic episodes Never cyclothymic Not solely in context of chronic psychosis Not GMC, substancerelated Not solely during delirium No other mood disorder better explains symptoms.

Cyclothymic

General Medical Condition

Clinical distress or impaired work, social, personal functioning

Not solely during delirium No other disorder better explains symptoms.

Patient is sad, tearful, hopeless

Schizo- Adjustment affective disorder w/ depressed mood

Distress > expected for stressor, or impaired work, social, personal functioning

Doesnt fulfill criteria for other Axis I disorder; Not bereavement

2+ of: delusions, hallucinations, disorganized speech, disorganized or catatonic behavior, or negative symptoms

For 2+ wks, delusions and hallucinations w/o prominent depression

Not directly caused by GMC, substance misuse

Chapter 5

Psychosis and Schizophrenia

If youve ever had a dream in which you were being watched, perhaps followed, where everyone knew something you didnt, then youve had a taste of what it is like to be psychoticexcept that if youre psychotic, its still happening when you wake up. Psychosis is a devastating, alienating experience that mystifies and terrifies everyone it touches, sometimes even the doctor. John Nash was a solitary, lonely little boy who stayed indoors to read when others were outside playing. As a child, John had no close friends. He talked a lot, daydreamed, and had trouble following directions, though he carried out scientific experiments in his room at age 12. A brilliant mathematician (he started graduate school at age 20), even in college he was considered snobbish and odd by his peers, who noted peculiar behavior such as playing a single chord on the piano or leaving ice cream to melt over clothing hed taken off. His parents (who were loving and sympathetic) and his younger sister all recognized that he was different, odd. At age 30, he became acutely and severely psychotic. He imagined he had a central role in combating threats to world peace, that powers from outer space were communicating with him through the New York Times. He thought that his bridge partner could read his mind, and he noticed that men were wearing red neckties in an effort to send him signals about a crypto-communist party. In a letter (written in four colors of ink) he complained that space aliens were ruining his career. He believed that he was to become Emperor of Antarctica and that Life magazines cover photo of Pope John 23 was really one of him. (Supporting evidence: he noted that John wasnt the Popes original name, and that 23 was his, John Nashs, favorite prime number.) His thinking unhinged and his behavior increasingly erratic, he was finally admitted for the first of several psychiatric hospitalizations. He referred to himself as the Prince of Peace and The Left Foot of God. He was diagnosed as having paranoid schizophrenia and treated with chlorpromazine, which markedly reduced his delusions. Over the next 30 years he was intermittently extremely psychotic; one time in Italy he heard voices like telepathic phone calls from individuals. He concluded that the Italian words were being fed into a machine that translated them into English and inserted them 69

Psychosis into his brain. A letter he wrote when he was 39 read in part: If all the atomic powers of the security council of the United Nations did an action, and they were numbered 0, 1,2,3,4 then one would be able to say nobody did it, everybody did it, all did it He put salt and pepper into his tea, then complained that it tasted bad, and once poured water onto those who passed through a doorway below him. By that time, he had already published the work that led to his 1994 Nobel Prize in economics.

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Symptoms of psychosis
The history of John Nash illustrates some of the psychotic symptoms found in people with psychosis. The five principal symptom areas are: (1) delusions, (2) hallucinations, (3) negative symptoms, (4) disorganized speech, and (5) disorganized behavior. Each of them carries the message that the patient is in some way out of touch with reality. Delusions. These are false ideas or thoughts that a person believes to be true, no matter how improbable. Many types of delusions are possible, such as believing that you can read minds, that the television is sending encoded messages especially to you, or that electrodes have been secretly implanted in your brain. The most common delusions in schizophrenia are those of persecution (someone is following, spying upon, or trying to harm you); John Nash had many such delusions, such as those about space aliens and being a religious figure. All sorts of real events and conditions can get pulled into these delusions. I once treated a woman who had ankle edema due to kidney disease. She thought that water was being pulled downward into her legs by gravity machines installed in her basement by Nazis (shed been ill a long time, and this happened many years ago). Whatever the content of the delusional belief (they are covered in greater detail in the chapter on interviewing), it is fixedthe person cannot be persuaded that it is false. Not included are widely held cultural beliefs, such as ghosts and, for kids, Santa Claus. Brief definition: a delusion is a fixed, false belief. Hallucinations. A hallucination is a sensation that the person only imagines. It can involve any of the five senses, but hallucinated sounds are the most common in schizophrenia. At one time, John Nash heard voices like telepathic phone calls. Typically in schizophrenia, these voices seem entirely realsometimes coming from far away, sometimes close by or just outside the room; still other patients hear them in their heads. Patients often recognize these voices, but sometimes they are of strangers. There may be one voice or many that can ridicule, threaten, command or, infrequently, soothe. In the Oscar-winning film of A Beautiful Mind, the John Nash character, as portrayed by Russell Crowe, appears to have ongoing visual hallucinations of imaginary friends. Judging from the biography by Sylvia Nasar, this was entirely a fiction. Although schizophrenia patients can have visual hallucinations, typically these (as well as hallucinations of smell, taste, and touch) are found in psychoses due to physical disorders. Negative symptoms. This concept embraces several behaviors that suggest something is missing from the patient, not added to, as is true of with hallucinations and delusions. An obvious negative symptom is flat affect (also know as affective blunting), in which the individual shows little emotionno lilt to the voice, poor eye contact, and little in the way of facial expression or hand gestures. Another is a lack of volition, which John Nash may have shown to a degreefor many years his attention was so preoccupied by his delusions that he could do little math.

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Other negative symptoms are alogiatalking very little, even when the situation calls for extended speech; and anhedoniathe inability to enjoy once-pleasurable experiences. Disorganized speech. The speech of some patients becomes stilted or cluttered and may contain made-up words. Such speech may have meaning for the individual, but another person might be hard-pressed to understand. Sometimes called loose associations, disorganized speech moves from one idea to another without an obvious thread. The fragment of John Nashs letter quoted in the vignette demonstrates a degree of disorganization. Disorganized behavior. When severely psychotic, Johns behavior was occasionally disorganizedfor example, adding salt and pepper to his tea. Psychotic patients may become extremely excited, engaging in frenetic activity that often does not appear goal-oriented. On the other hand, they may grimace, maintain postures for many minutes, or perform rituals that have meaning only for them. A patient whose psychosis is dominated by disorganized behavior is sometimes referred to as catatonic. John Nash was never violent, an especially serious consequence in some instances of psychosis. However, psychotic patients are not usually violent; in fact, intentionally harming another person is unusual. It can happen, however, as in the case of Sam Berkowitz, the serial killer who, as Son of Sam, terrorized New York City women in the 1970s. Another such patient was the killer of University of California student Tamara Tarasoff. The consequent lawsuit led to the Tarasoff ruling, which requires mental health workers to protect people from a mental patients threats, either by reporting them to the police or by other means. Patients with schizophrenia often become suicidal, however, and 1015% eventually take their own lives. The risk of either tragic outcomesuicide or violence against othersis only one reason to provide careful diagnosis and competent treatment for psychotic individuals. ( See pages 85 and 50 for further discussions of violence and suicide.)

Differential diagnosis
Besides indicating a variety of symptoms, the word psychosis can also mean a class of illness that includes schizophrenia and other, less well-known disorders. Here is a reasonably complete listing: Psychosis due to substance use Psychosis due to a medical condition Isolation psychosis (e.g., prisoners in solitary confinement)** Delirium with psychosis Dementia with psychosis Mood disorder (bipolar I or major depressive disorder) with psychosis Schizoaffective disorder Schizophreniform psychosis Schizophrenia

Schizophrenia
The best-known chronic psychosis is schizophrenia. For convenience, everyone speaks of it as a single entity, though in reality its probably a group of diseases that have many symptoms in common. It is one of the most important public health problems in the United States, by some

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72

estimates costing as much as all cancers combined. In recent decades, improved treatment has enabled the release of many chronically hospitalized patients into their communities, though follow-up care has lagged so far behind that many stop taking their medicines and relapse. So many end up living on the streets that, in larger cities, up to half the homeless have some form of psychosis, most often schizophrenia. They gravitate to petty crimes and misdemeanors, thus becoming wards of the criminal justice system. The symptoms of schizophrenia are many and varied. Of course, the percentages will vary, depending on the series reported. Delusions. The vast majority of schizophrenia patients (over 90%) have delusions at some point or other. In schizophrenia, persecutory delusions are by far the most common. Hallucinations. About half of all schizophrenia patients experience hallucinations; auditory predominate, but about 15% report visual hallucinations. Abnormal behavior. Between 5 and 10% will have symptoms of catatonia, such as stupor, negativism, stereotypies, posturing, and catalepsy. Abnormalities of appearance may include bizarre clothing and grooming styles, poor hygiene (as was true of John Nash at the height of his illness), and hyperalert scanning of the environment for threats or the source of voices. Overall, around 15% of patients show significant abnormalities of behavior. Perhaps 10% of schizophrenia patients become aggressive; a few will commit violent acts ranging from simple assault to attacks that lead to severe injury or death. Violence is especially likely in patients who are young, male, have a past history or violence, refuse medications, and misuse substances such as alcohol and street drugs. However, the majority of schizophrenia patients are no more prone to violence than is the general population. Disordered speech. Derailment and tangentiality are found in roughly half of schizophrenia patients; around a quarter are illogical or incoherent. Disordered emotion. Around 20% of acutely ill patients show inappropriate affect (usually considered a positive symptom of schizophrenia); around half display affect that is flattened or blunted. Around 40% of schizophrenia patients experience anhedonia (the loss of feeling). Psychotic patients may also respond inappropriately to other peoples emotionslaughing at someone elses grief, for example, or giggling without obvious cause. Around 70% of acutely ill, but only around 10% of chronically ill schizophrenia patients experience depression. Some become depressed as they begin to recover and gain insight. One of my earliest patients as a medical student was a psychotic (yet insightful) young woman who cried bitterly, stating that she knew she had schizophrenia and feared she would end life on a back ward of a state hospital. Apathy. Over two-thirds of schizophrenia patients are apathetic, as shown by low energy, poor grooming or hygiene, or lack of persistence in school or on the job. There is often loss of usual interests, including interest in sex with other people. Attention and cognition. Half of patients are inattentive, in social or testing situations. Working memory, long-term memory, the ability to abstract and plan, and language comprehension are all compromised. Insight. My early medical student patient notwithstanding, typical insight in schizophrenia is terrible. With denial of illness, judgment falters, sometimes fatally, as patients fail to adhere to treatment recommendationslike John Nash. Various medical consequences. Heavy cigarette smoking is the rule, and patients may abuse substances (some clinicians think that alcohol and drugs may serve as home remedies for

Psychosis hallucinations). Their sleep may suffer; relatives sometimes note that they hear acutely ill schizophrenia patients pacing and mumbling to themselves throughout the night.

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Schizophrenia subtypes
We commonly recognize several subtypes of schizophrenia, characterized by the presence or absence of the now-familiar five basic symptoms: Paranoid. Persecutory delusions characterize people with paranoid schizophrenia, who may seem pretty normal unless a topic related to their delusional ideas comes up. Paranoid schizophrenia often begins later than the other subtypestypically, when the patient is 30 or older. Disorganized. These patients think and speak illogically. Facial expressions and mood tend to be stiff or unchanging, though some patients may laugh or giggle inappropriately. Behavior may be bizarre and not understandablecarrying around collections of paper cups or gesturing in ways you cannot understand. Catatonic. Abnormalities of motion are prominent. These include frozen postures (holding uncomfortable poses, sometimes for hours at a time) and pronounced negativism, such as a patient turning away from an interviewer. Undifferentiated. This term is used when the patient doesnt meet full criteria for any of the three subtypes listed just above and in Table 6. A diagnosis of exclusion, it is the type most commonly diagnosed today. (A strong minority of patients has paranoid subtype, whereas the number of disorganized and catatonic types is relatively small.) Residual. With treatment, most patients improve enough that they eventually lack sufficient criteria for a diagnosis of acute schizophrenia; then, we say the patient is in the residual phase. This person is still ill: Youll still find a few negative symptoms such as flattened affect, lack of volition or reduced speech output, or there will be remnants of positive symptoms such as odd manner of self-expression (from disorganized speech), illusions (related to hallucinations), odd beliefs (from delusions) or peculiar behavior (from disorganized behavior). Although these subtypes seem pretty clear-cut, in practice patients may change subtypes more than once in the course of a long illness. Indeed, John Nash, called paranoid schizophrenia for many years, at times had disorganization of his thinking and behavior; in hindsight, undifferentiated might seem a more appropriate diagnosis. But in the end, it doesnt make much practical difference: the subtype designation confers little predictive information, beyond the simple diagnosis of schizophrenia itself. Making the diagnosis Because it falls so low on the safety hierarchy, clinicians shouldnt diagnose schizophrenia unless a patient has had symptoms for at least 6 months. Besides the requisite symptoms and time duration, we must also be careful to rule out other possible causes of psychosis. These include mood disorders with psychosis, general medical and substancerelated illnesses that have psychosis as prominent symptoms. The symptoms must also have been serious enough to cause impairment of the patients work, social or personal life. The criteria are summarized in Table 6 (page 87.

Course of illness
In a number of ways, John Nash is typical of schizophrenia patients. Before he fell ill, he was an isolated, quiet young man with few friends. This personality type, sometimes called schizoid,

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occurs in about 25% of patients (schizotypal and paranoid are the other personality disorders that sometimes precede schizophrenia). However, most people with abnormal personalities do not develop schizophrenia, and many schizophrenia patients do not qualify for a personality disorder prior to falling ill. By far the majority of patients are young (teens and 20s) when they first fall ill. The onset of schizophrenia is usually gradual; then, most patients pursue a chronic course. This means that, even with competent treatment, patients continue to have mild symptoms or are at risk for relapse if they discontinue medication. John Nash always responded well to antipsychotic agents, but refused to take them consistently, thereby leading to years of reclusive unemployment. In his mid-50s, he became better able to ignore his delusions; once again he could do mathematical research. His improvement provides an excellent example of residual phase schizophrenia. Other, less fortunate patients remain so ill that, to live in the community, they require careful supervision of their medications. Some become street people, and a few cannot survive at all outside the walls of an institution. The suicide rate among schizophrenia patients, about 10%, is especially high in younger patients and in men who have been recently diagnosed, depressed, or unemployed. Those who have been recently discharged from a hospitalization are at greatest risk. Even excluding suicide, the overall lifespan of schizophrenia patients is around a decade shorter than for non-affected Americans. Contributing factors include cigarette smoking, substance use and poor nutrition, through the mechanisms of cancer, coronary artery disease, diabetes and high blood pressure.

Sidebar: Improvement and Recovery

Trying to predict outcome has occupied researchers for many decades. It is especially difficult for new-onset patients who have not been ill very long; after 5 years of illness, it is safe to predict continuing illness. In the short term, those who are likely to experience an outcome that is better than average tend to be characterized by some of the factors listed below. Asterisks indicate those features that are potentially modifiable. Short duration of untreated psychosis.* One of the most robust findings is that a brief duration of symptoms prior to initiation of treatment is associated with quicker remission, more stable remission, fewer positive symptoms, and improved functioning in social settings. Early (within, say, 6 weeks) positive response to treatment. Good personal, social or work-related functioning at intake. Female sex. Women with schizophrenia are more likely than men to have good interpersonal relationships and to live independently. Cognitive remediation.* Using group formats to teach strategies to improve cognition can improve cognitive performance (including memory, attention, and executive functioning) and psychosocial functioning. Sticking with treatment.* Psychiatric education.* Teaching patients and relatives about the basic facts of psychotic illness, such as symptoms, treatment adherence, patient functioning, and rehospitalization appears to reduce relapse rates, at least over the short term (one year).

Psychosis On the other hand, a poor outcome may be heralded by:

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Early onset of illness, even into the early teens and before. Poor insight (not just related to poor compliance). Poor insight is reported in 50-80% of schizophrenia patients. Poor early response to treatment. Poorer social functioning at intake. Many months (even years) of initial untreated psychosis.* One study reports that those with longer times to treatment experienced greater reductions in grey matter volume. The presence of negative symptoms at baseline. Greater severity (e.g., more positive symptoms) at onset of disease. Misuse of substances such as alcohol and street drugs.* Cognitive impairment. Poor compliance with medications.* This is a major contributor to relapse. In some way at some time, over half of patients will not adhere to treatment regimens. Of those who do not take medications, upwards of 80% will relapse within 5 years; even partial noncompliance is related to relapse. Oral atypical antipsychotics are complied with better than traditional oral agents. For those at the more extreme end of this range, use of depot drugs may provide some benefit; now, depot risperidone is available. Unrecognized depression that leads to suicide attempts or completions.* Overall suicide prevalence is probably around 5%. The greatest danger comes in the first year after diagnosis, but risk continues throughout life. Treatment with traditional neuroleptics doesnt reduce the suicide rate much, though clozapine has been reported to reduce suicidality.

Another intriguing, well-substantiated finding is that patients in low- and middle-income countries such as India, Singapore, and Hong Kong tend to have better outcomes. That is, despite a sometimes long duration of untreated psychosis, compared to patients in most Western countries they are better socialized, more likely to be employed, and much more likely to be married. This finding may be related to psychosocial factors such as relatively low substance use. Contrary to the usual view of schizophrenia as a chronic disease, a few patients appear to recover completely, whether or not they take medication. Their numbers are not largeperhaps around 10%, depending on the studybut they are well-documented: patients who would meet any set of rigorous criteria yet on follow-up after months or years appear free of all symptoms and restored completely to their premorbid functioning. There are few studies of these incredible patients, and not much is known about how to predict this astonishing outcome.

Epidemiology and etiology

Known for centuries, schizophrenia is far from rare todayabout 1% of all adults have itand it is found in every culture on earth. Typical age of onset is in the late teens or early 20s, though the paranoid subtype may begin in the 30s, 40s or even later. For reasons still not understood, males tend to develop it a few years earlier than females, though overall it affects men and women about equally. It is encountered more often in disadvantaged social and economic groups, probably because so many schizophrenia patients cannot take good care of themselves and descend into povertythe social drift theory of schizophrenia.

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Most researchers believe that schizophrenia is a collection of disorders with a variety of causes. In many cases, the disorder probably has more than one root cause. By the time John Nash fell ill in the early 1950s, a genetic component to schizophrenia had been well-established. Although most relatives of patients with schizophrenia do not have a mental illness, first-degree relatives have 510% chance of developing the disease. (One of John Nashs two sons, also a mathematician, had the disease.) The greater the genetic loading, the greater the risk; a child of 2 ill parents runs a nearly 50% chance of developing schizophrenia. Indeed, dozens of studies have shown beyond doubt that what we inherit accounts for half or more of the risk of developing schizophrenia. Over the years, additional diverse factors related to the brain and neurological functioning have expanded the areas in which the search for the etiology of schizophrenia must be conducted: Size of ventricles is larger on average in schizophrenia patients than in matched controls; this abnormality appears to be present at least from the onset of the disease. Patients may also have less total brain tissue and grey matter (and more CSF). Factors as diverse as prenatal exposure to viruses (more people with schizophrenia are born during the winter months) and obstetric complications suggest a role for injury to the developing brain (this process extends through the late teens into the 20s, well within the usual age of onset). Response to medications have led to hypotheses that a disturbance in neurotransmitters may set up vulnerable patients for psychosis. Dopamine has long been the dominant suspect, based on two findings: (1) the dopamine blockade caused by the older, typical antipsychotic drugs, and (2) amphetamine psychosis may be mediated by increased dopamine activity. Weinberg suggests that reduced dopamine activity may be responsible for negative symptoms such as lack of volition, whereas increased dopamine activity may be related to delusions and hallucinations. Of course, the fact that atypical antipsychotic drugs block both dopamine and serotonin receptors suggests a more complicated overall picture. Glutamate, yet another neurotransmitter, has also been implicated. Over the decades, social factors have been explored. An excess of schizophrenia in second-generation immigrants suggests social causation, such as exposure in childhood to adverse social conditions. The excess of schizophrenia patients among the lower social strata is probably best understood as the downward mobility of the social drift hypothesis. And chaotic, highly emotional family life may contribute to symptom relapse, but does not itself appear to be causative.

With so many threads in the tapestry left untied, it is clear that we are still far from completing our picture of what causes schizophrenia. The balance of the evidence suggests that a multiplicity of factors must be in play: a genetic diathesis released by developmental factors such as obstetrical complications, poor prenatal care or maternal substance use and by stressful environmental factors later in life.

Comorbidity
Substance use (especially nicotine, used by about 80% of schizophrenia patients) is a frequent complicating factor. Depression, obsessive-compulsive disorder and panic disorder are the other psychiatric conditions that often occur. Weve already mentioned the three personality

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disordersschizoid, schizotypal, and paranoidthat may be present for years before the onset of acute illness.

Editorial: Caution Advised

Throughout the Twentieth Century, many patients were diagnosed with schizophrenia who later turned out to have another illness entirely. This error still happens today, partly because psychosis is a confusing condition that can take many forms, partly because clinicians sometimes dont give enough thought to the diagnostic process. The error is extremely serious because an incorrect diagnosis of schizophrenia can promote treatment that is lengthy, unnecessary, and sometimes even dangerousas well as delay treatment that is appropriate and effective. Accurate diagnosis depends on knowing not just the symptoms but the patients lifetime course of illness. In schizophrenia, the course is usually chronic, which means that once illness strikes, most patients do not resume their former level of functioning, though they may improve greatly. Contrast this prognosis with that of a psychosis caused by substance use or a physical disease, which usually remits completely once the underlying illness has been addressed successfully. People with psychotic bipolar mood disorder also usually recover completely. A number of features can suggest that a patient does not have schizophrenia: abrupt onset, mood symptoms (mania or depression), a strong family history of mood disorder, brief course (symptoms present less than 6 months), good social adjustment prior to becoming ill (reliable worker or student with stable personal relationships); upsetting emotional factors (such as death of a parent) that could conceivably cause psychosis; and symptoms beginning later than age 30.

Treating schizophrenia
Even 50 years ago, schizophrenia carried an especially gloomy prognosis; many patients spent years in mental hospitals. Now, with effective treatments that can return them to their lives, jobs, and families, the outlook is much brighter. Many patients work, though their jobs may be less complex than education and training has prepared them to do. Although most do need long-term treatment, they are far less likely than those of their grandparents generation to require chronic institutional care. Acute phase For most disorders, there are psychotherapy alternatives for patients who dont want to take drugs. Schizophrenia is an important exception. Although psychotherapy can help manage schizophrenia, it is not effective as a sole treatment; medication is indispensable. Moreover, it is important to begin drug therapy at once: considerable data suggest that effective medication early in the course of the illness, with consistent follow-up care, reduces the likelihood of relapse and limits social declinepossibly because early treatment averts changes in brain structure. The treatment of all schizophrenia subtypes is about the same. For example, start with one of the atypicals, perhaps olanzapine (Zyprexa), 5 or 10 mg once a day, then increase it gradually, at weekly intervals, until the target symptoms begin to disappear. A 46 week trial is generally accepted as a standard treatment trial for any of the antipsychotic agents. If the first choice isnt effective, risperidone (Risperdal) or quetiapine (Seroquel) instead might be. For the first month

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or two, someone who is psychotic and acutely agitated may also need calming with a benzodiazepine such as lorazepam (Ativan) or clonazepam (Klonopin). Previous experience is one of the most important factors to consider in choosing from the growing list of available drugs. A drug with few side effects that has worked well in the past (and that the patient will accept) should perform well again. Usually, avoid the older antipsychotic agents in favor of newer ones. They have relatively few immediate side effects, so patients are more likely to accept them, and they are far less likely to have longer-term side effects, especially tardive dyskinesia (TD). The newer drugs are also more likely to improve disorganized thinking and negative symptoms. Because they have so many more side effects, prescribe one of the older drugs only if the patient is already well established on it without major side effects or newer drugs havent worked. Watch carefully for evidence of tardive dyskinesia or another movement disorder. Every 6 months, administer the Abnormal Involuntary Movement Scale (AIMS). If an older antipsychotic is needed, doses below the equivalent of 300 mg/day of chlorpromazine will probably be ineffective, and doses above 1000 mg/day arent likely to improve response. Note that most studies find there is very little difference in response rate among the older antipsychotics, as long as they are given in adequate doses. For someone whos been taking an older drug for many months, consider changing to a newer agent, to reduce the risk of TD. When making any change, the usual practice of gradually tapering off the current drug should be followed. Clozapine (Clozaril), the original atypical antipsychotic agent, has the longest track record of success in patients who are especially difficult to treat, but it occasionally causes agranulocytosis. Thats why clozapine is usually reserved for patients who simply dont respond well to other treatments. A treatment period of 6 months or more may be necessary to determine whether this drug will help. Because of its side effects, clozapine may be underutilized, but it is still the best-studied atypical, and it has the best track record in studies. How well patients accept any drug depends a lot on their comfort, so side effects must be corrected quickly. This is especially the case with the older antipsychotics, but even the newer ones can cause weight gain and metabolic problems such as an increase in serum glucose and lipids. Every 6 months, check to see whether patients show any symptoms of TD. Other movement disorders such as akathisia or parkinsonism can be addressed fairly easily by adding an antiparkinson agent such as trihexyphenidyl (Artane). Many patients refuse oral medications. Some may resent being controlled by doctors or think that medicines are harmful or unnecessary. For one who has repeatedly discontinued oral medication, the best solution may be a drug that can be given by injection once or twice a month, such as haloperidol (Haldol) or fluphenazine (Prolixin). Of the atypical antipsychotics, risperidone (Risperdal) is now also available in a depot form. Several forms of psychotherapy can augment the effects of medication. A recent metaanalysis found that cognitive-behavioral therapy (CBT) may help reduce the severity of delusions and other symptoms. Family therapy can help prevent relapse, especially when a lower-key approach can be urged on relatives who are overly involved with and critical of the patient. Social skills training seeks to improve patients adaptation to the environment, thereby reducing stress. The acute phase of illness is an excellent time to bring the family in for education about symptoms, early relapse, medication use and side effects, problem solving, and communication skillsfor example, how to request cooperation without alienating the patient. This information

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can help decrease the stress for both patient and family; it could even help prevent relapse. Finally, the case management skills of a social worker who periodically visits the patient in the community can help assure good continuity of care. Poor treatment response Using multiple antipsychotic drugs usually only piles one side effect upon another, but there are several steps you can take in the face of a poor treatment response. Be sure that your patient is really taking the prescribed medications (blood level checks can help determine this). Has the patient used this treatment long enough? Some apparently refractory patients just take longer (perhaps months) to improve. Remember that cognitive deficiencies and negative symptoms are better treated with atypicals than with the traditional antipsychotic drugs. Anyway, improvement in cognitive symptoms is likely to be modest. An adjuvant treatment may be helpful. For example, in a 2008 study, the use of estradiol (100 g/day patch) seemed to reduce positive (though not negative) psychotic symptoms when compared with antipsychotic drugs alone. Other potential adjuvants include lithium, carbamapezine (Tegretol), and divalproex (Depakote). For a schizophrenia patient who has been depressed, consider using antidepressant medication. ECT may relieve persistent catatonic symptoms. Some studies have found repetitive transcranial magnetic stimulation (rTMS) effective in treating negative symptoms.

Maintenance phase Once the patient has stabilized and has no hallucinations or delusions, the physician, patient, and family will share two goals: reduce medicine to the absolute minimum needed to prevent recurrence and watch carefully for symptoms of relapse. In some cases, such as with a first episode, it may be advisable to scale back the medicine very gradually, perhaps by about 20% every 6 months. If symptoms resurface, it will be easy enough to increase the dose again, before they can become severe. When patients stop drug treatment completely, it is important to watch carefully for recurring symptoms.

Schizoaffective Disorder
Here is a confusing diagnosis that, in my opinion, deserves to be left out of introductory textbooks; unhappily, it comes up too frequently to be ignored. The term was introduced in 1933 by a well-meaning doctor named Jacob Kasanin, who used it do describe 9 patients who had both psychotic and mood symptoms. Because this description fits a lot of patients (many schizophrenia patients are at some time depressed), the term took off. In the intervening 75 years, it has only grown more popular. Now it is used loosely by some clinicians, and very loosely by others: A few years ago, one psychiatrist famously wrote that he gave this diagnosis to most of his patients! Historically, however, the concept is important in that it helped us understand that not all psychosis is schizophrenia.

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When in 1980 DSM-III was first published, schizoaffective disorder was the only diagnosis listed that included no criteria whatsoever. Criteria were added in DSM-III-R in 1987, and revised again for DSM-IV. Currently, the term designates patients who simultaneously meet the A criteria for schizophrenia and, for a substantial part of the illness, also have a major depressive, manic, or mixed mood episode. For at least 2 weeks, the individual must have had delusions or hallucinations without prominent mood symptoms. Once identified, you can specify a subtypebipolar or depressive. There are some serious problems with these criteria, besides the fact that few of Kasanins original patients would qualify. For one thing, they arent derived from hard evidence that they can actually predict anything. For another, it is difficult to ascertain the absence of mood symptoms, especially when this determination is likely to be retrospective, made by people who are very concerned about and focused on the drama of an ongoing psychosis. (The requirement of no mood disorder symptoms for a substantial period of time is only one of the ways in which DSM-IV criteria differ from those of ICD-10, which only requires a balance of mood and psychotic symptoms). Finally, both the inter-rater reliability and diagnostic stability for schizoaffective disorder appear to be low. In recent years, numerous reviews have failed to substantiate schizoaffective disorder as a separate, discrete diagnosis. Some experts regard the concept as a psychotic mood disorder, others see it as either a middle ground in a spectrum between mood and schizophrenia or a collection of cases from both categories. We think that by diagnosing schizoaffective disorder, weve achieved something. In my view, that accomplishment is to muddy the diagnostic waters and, possibly, to distract us from making a diagnosis that can actually predict something about the patient. Some clinicians worry that using the term could lead to treatment that is substandard.

Schizophreniform Disorder
No difficulties with criteria present themselves with schizophreniform disorder. Thats because this term is really just a place-holder, an acknowledgment that the clinician isnt sure enough to make a definitive diagnosis. Devised in 1939 by Gabriel Langfeldt in Germany, schizophreniform disorder is defined exactly like schizophrenia, except that its total duration must be less than 6 months. This time frame reflects the findings from study after study that patients who have had psychotic symptoms for briefer periods of time may recover completely. Once 6 months have passed, the patient must be rediagnosed. If the symptoms persist, you will probably diagnose actual schizophrenia. If they have remitted, you may change the diagnosis to something different such as a mood disorder with psychosis or a psychosis caused by a medical illness or by substance use. If we do use the designation schizophreniform disorder, we are encouraged to assign prognosis, based on several factors. A patient will be relatively likely to recover (that is, not progress to a chronic course of illness) if any 2 of the following features are present: The actual psychotic symptoms begin within 4 weeks of the first noticeable change in the patients behavior or functioning. When most psychotic, the patient seems confused or perplexed. Premorbid social and job functioning are good. Affect is neither blunt nor flattened.

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I feel that schizophreniform disorder is sadly underused. It is of great value to defer diagnosis of schizophrenia until you can be as certain as possible that you havent missed some other diagnosis that has a better prognosis.

Delusional Disorder
Schizophrenia patients have two or more different psychotic symptoms; those with the much less common delusional disorder have only onedelusions. Orville started out in the nursery business with his father, then ran it alone for several decades after his father died. He was nearing 65 himself when he became convinced that his neighbor was stealing precious orchids from him. He had repeatedly called the sheriff to complain and he yelled in outrage when no one took him seriously. When he sent the neighbor (courtesy copy to the sheriff) a typewritten note threatening to use my .44 if his greenhouse wasnt left alone, he was finally committed to the county mental health unit. His son told the caseworker that Orville didnt have any precious orchids, only some cymbidiums that he had nursed back to life when the local KMart tossed them out after Christmas. He had no hallucinations or other psychotic symptoms. Twice in the last couple of years he had been taken to a private psychiatric hospital, but each time he had refused medication and left against medical advice. The delusions can be of several types: Persecutorylike Orville, the patient feels in some way intentionally cheated, drugged, followed, slandered, or otherwise mistreated. This is by far the most common subtype. Grandiosethe patient has a special talent or identity, such as being a rock star or Jesus. This type appears to be rare. Erotomanicsomeone, often of status higher than the patients (such as a television actor), is in love with the patient. Jealousthe individuals partner has been unfaithful. This may be more common among men than women. Somaticthese people believe that they have some physical illness or defect, such as delusional infestation by parasites. These delusions are not bizarrethat is, the ideas or events could conceivably happen (as opposed to extravagant beliefs such as being abducted and probed by Martians). Except when discussing the content of the delusion, these patients can seem quite normal, hence the term encapsulated delusions. When they do talk about their delusions, they express them with appropriate affect, just as Orville was outraged that his calls to the sheriff had gotten no results. Delusional disorder is more common in women than men, and the patients are often widowed and middle-aged or older. It is rare as psychoses go, with a prevalence of perhaps 3 in 100,000 persons, so studies adequate to determine etiology have not been done. Best guesses currently deny a significant genetic relationship between delusional disorder and schizophrenia. Especially beware organic causes of delusions in patients who are older and have no family history of psychosis. There are many possibilities; examples include Wilsons disease, cerebrovascular disease, and dementia.

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Treatment and course

If they can be persuaded to take medicine, most delusional disorder patients greatly improve, especially if treatment begins without delay. Over the past few years, the traditional neuroleptic drug most recommended for delusional disorder has been pimozide (Orap). However, the need for medication may be permanent, so one of the newer antipsychotics should be tried first. If these drugs dont seem to work, some patients appear to respond to an SSRI. Psychotherapy alone is of no value, but the familys involvement is at least as important as in schizophrenia. Untreated, delusional disorder is a chronic, unrelenting disorder that interferes with work and alienates people from their families and friends.

Psychosis Due to Medical Disease Or Substance Abuse

When Helen was 24, a serious automobile accident required her to undergo several blood transfusions. She didnt learn until 10 years later that she had contracted hepatitis C. After taking the prescribed interferon for several weeks, she complained to her doctor that she felt tired and grouchy and that she heard talking when no one was around. The voice was her ex-husbands, and it told her to stop the interferon because it was causing her hair to fall out. Laboratory testing showed that Helens thyroid gland had almost stopped workingprobably an effect of the interferon. With replacement thyroid hormone therapy, her hallucinations vanished and she successfully completed the treatment for hepatitis. For at least 20 years, Danny had been a heavy drinker, consuming over a pint of bourbon a day. When he developed what he called stomach flu, he stopped drinking. Within a few days he began to hear chanting; he wondered whether someone had put a transmitter into his ear. By the time he finally sought mental health care, he could hardly concentrate voices yelled Dont tell them about your drinking! and Why dont you just kill yourself? He was so terrified that he admitted himself to a locked psychiatric ward. Despite an admitting diagnosis of schizophrenia, within 2 weeks the voices melted away without medications; a consultant rediagnosed his condition as an alcohol-induced psychosis. These two vignettes demonstrate that psychosis can be caused by physical illness or substance misuse. The important issue is not that they are so very common (indeed, it is difficult to come up with prevalence or incidence ratesin all likelihood, neither situation is especially common or rare). Rather, because these two classes of diagnosis require treatment that is different from all other psychoses, and because missing such a diagnosis can be potentially catastrophic, they belong at the very top of every differential diagnosis for psychosis. They are the first causes to rule out, even if they are (usually) not the most likely. These etiologies occur just infrequently enough to lull us into inattention. As with Helen and Danny, the best approach is not to address the psychosis directly but to treat the underlying disorder. Although you may never encounter a psychosis due to interferon, the list of medical disorders that include psychosis among their symptoms is long. It includes adrenal insufficiency, AIDS, brain tumors, strokes, chronic obstructive lung disease, Cushings syndrome, epilepsy, Huntingtons disease, hyper- and hypo-parathyroidism, hyper- and hypo-thyroidism, Lyme

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disease, normal pressure hydrocephalus, porphyria, and tertiary syphilis. And thats just a few of them. As with Danny, a mistaken diagnosis can complicate a patients life for years to come. Alcohol is by far the most common substance-use cause of psychosis; however, a great variety of drugs (street and prescription) can also be the culprit. Others include amphetamines, cannabis, cocaine, the hallucinogens, inhalants, opioids, and phencyclidine (all during intoxication). Sedatives and alcohol are associated with psychosis during either intoxication or withdrawal.

The physicians approach to patient and family

Because psychosis lies far outside the life experience of most students, schizophrenia patients are among the most difficult for trainees to work with. Following are some basic guidelines for dealing with psychotic thinking and the behavior that can result. An approach to psychotic thinking Our own discomfort sometimes prevents us from discussing delusions frankly; but when we encourage communication, we allow the patient to express fears and concerns that might otherwise have no outlet. To help the patient feel listened to, ask open-ended questions. Later, request clarifications as needed. Avoid directly confronting hallucinations or delusional thinking. Its not real is a losing strategy with someone for whom auditory hallucinations are as real as the music on your iPod is to you. Instead, ask for a description of the experience (Tell me exactly what you hear). This could allow the patient the relief of communicating sensations that may have had no other outlet. Key into the patients experience, not the alleged source. For example, to a patient who hears the voice of God, What message do you hear? not What did God say? In trying to ascertain how firmly a patient holds an idea that may be delusional, a question such as Could it be that or I wonder whether gives the patient space to reconsider, possibly to volunteer a nonpsychotic conclusion. Accept whats said, carefully monitoring your facial expressions and body language so as not to show disbelief. Acknowledge the content of the delusion or hallucination and the emotion carried with it. Label this emotionfor example, sad, angryand ask the patient how it feels. By emphasizing emotional elements, you can sympathize with even the most outlandish stories, That must have felt horrible. Agree that the patient has a right to these feelings, whatever they are. Acknowledge their reality, even if you disagree with the content. If I thought that someone was reading my mind, Id feel pretty upset, too. On the other hand, dont try to enter into the psychotic symptom; e.g., mock-exorcise a demon or wash away bugs crawling on the skin. Such behavior reinforces the patients hallucinations or delusional thinking. The same line of thinking suggests we shouldnt succumb to a request for our trust. So, to the question, Do you believe me? respond I believe you feel this way, and I want to help you with those feelings. A reiteration of the original question might lead you to respond, I

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wonder if there could be some other explanation or Im having trouble understanding what youre telling me, but I recognize how important it is to you. Why dont people believe me when I say [the CIA taps my phone]? is the sort of question you might well be asked. Its reasonable to respond with (Why do you think it is? or What would you think I might say?) For suspiciousness, ideas of reference and other delusional material, offer a possible alternative explanation. For example, When under stress, anyone can become very sensitive and begin to interpret everyday events in a special way. And of course, never blow off depression and (especially) suicidal ideas; patients with clearcut schizophrenia become depressed and may commit suicide.

An approach to aberrant behavior For treatment refusal, try to present it (usually, medication) as a chance for the patient to regain control over illness. Sometimes this goes down better if it comes from other patients, perhaps during a ward meeting. Regardless of the behavior, resist the temptation to assert your authority. A psychotic patient is likely to pay scant attention to the rules and requests of someone who cannot even appreciate the fact of text messages sent by Elvis or Princess Di. Be careful what you promise. Establishing trust is hard enough without demonstrating that you are willing to go back on your word. Ill try my best to get you onto an open ward, but it probably will have to wait until you are feeling less angry. Your doctor saysso we have to comply puts you and the patient on the same side of nearly any issue. Ill be glad to speak with your doctor about more privileges, but I suspect Ill be rebuffed. You may have to continually refocus the patients attention. Yes, I understand that you worry about the voices in the hallway. But lets try to finish our discussion of your problems sleeping. Once the patient agrees to something (e.g., taking medication), offer thanks and then go on to another topic. You dont need to address that topic any more, further discussion of which might just cause the patient to reconsider. The warnings about safety apply strongly to psychotic patients, some of whom behave in unpredictable ways. In responding to aggression, talk quietly and try to avoid direct eye contact, which can seem confrontational. Signal early for help, and do your best to move out of the areacalmly but rapidly. Dont argue, and dont fight.

Finally, because patients (and their relatives) can be quite confused and often frightened, physicians should be extra careful to project a calm and reassuring demeanor. Try to find shared ground, something you can agree on, even if it is trivial. Its sure been a cold winter is a statement you can make that puts the two of you on the same side, providing a basis for relationship.

Brief Psychosis
Anyone whos been paying close attention might have noticed a hole in the line-up: with schizophrenia and schizophreniform disorder, we have all possible time intervals covered down

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to a month. But what about patients whose psychotic illness has lasted just a couple of weeks? Well, thats covered, too, in the poorly understood, rarely encountered brief psychotic disorder. These patients must have one or more of the classic symptoms: delusions, hallucinations, disorganized speech, and disorganized behavior (no negative symptoms). These patients may experience rapid shifts of intense affect. Onset tends to be within the same age range as schizophrenia, and may be apparently precipitated by a stress, such as childbirth, death of a relative or some other trauma. Completed suicide is a particular risk in this group. However, dont expect to encounter a lot of these people; in all my years of practice, Ive never seen one. If you do see a person who meets these criteria, observation may reveal the final diagnosis to be a psychotic mood disorder, or a psychosis due to a medical illness.

Shared Psychosis
And here is a truly fascinating condition, of which Ive encountered only one in over 15,000 psychiatric patients. These people apparently become psychotic because they buy into the delusion of someone with whom they are intimately connected. For example, the wife of a schizophrenia patient begins to believe his delusion that the Catholic Church has installed spyware on his computer. The wife would swear that this was happening in their home, might even adduce evidence to prove it. However, once separated from her husband, the strength of this belief would gradually wane and her delusions would fade away without medication or other specific treatment. This condition has been known for many years, originally as folie deux (the madness of doubles, or double insanity), though instances are recorded that involved three or more individualsalways one primary case who was delusional first, followed by others who come to share in the psychosis. Often, the primary case is the dominant individual in the home or partnership; many of the pairs (or trios, or even whole families) are isolated socially. The person with the shared psychosis usually comes to medical attention only when the primary patient is identified. If you ever encounter such a patient, write to meId love to hear.

Sidebar: Violence and Mental Disorders

The unhappy truth is, psychiatrists are little better than anyone else at predicting violent acts accuratelyits hard enough to foresee behavior within the next few hours or days, let alone weeks or months into the future. Over the years, weve learned some of the factors that are associated with violent behavior, but the leap wed like to make to accurate predictions has included rather too many missteps. Consider two scenarios: At age 21, Brenda drank and was a good customer for the amphetamines she cooked in a lab shed helped her boyfriend construct in his grandmothers basement. From age 11, she had repeatedly run away from home, partly to escape the beatings from her stepfather. Smart but unmotivated to study, her grades throughout school had been a series of Ds and Fs, and she had dropped out when she was 15 to drift in and out of juvenile hall. At 16, after consuming alcohol and other stuff at a rave, she stabbed and nearly killed another girl. Brenda was released from custody when she turned 21. Her parole officer recently

Psychosis noted that shed resumed drinking, and that several times shed threatened to finish the job on the girl she stabbed years ago. Brent, also 21, fell ill early in his junior year at university. Always a steady, earnest student, both Brent and his family were surprised at how quickly his grades tumbled once the voices he now heard began telling him he was the Devil. Academically, he just seemed to wither away, said his aunt, with whom he lived while attending school several hundred miles from where he grew up. After the first few weeks of the fall term, he gradually stopped going to class. He neglected his appearance and refused to go home for Christmas. By the end of April, he wouldnt even leave the house. When questioned, Brent said that he had come to realize that he was the Antichrist, and through him the world would be destroyed. His aunt told the clinician that her husband kept a pistol in an unlocked desk drawer; she didnt know, but she thought it might be loaded.

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Many clinicians might decide that Brents history of psychosis and the fact that he was young, male, and had apocalyptic delusions rendered him likely to commit a violent offense. However, over the years, traditional clinical methods have proven unreliable in assessing violence potential. A large part of the difficulty lies in the fact that studies of violence are often based on general population samples, whereas physicians want to know how likely a particular patient is to commit an act that will harm someone else. To answer this question, researchers have developed actuarial models that rely less on clinical information and judgment, more on data from records and demographics. Some of the findings are surprising. Diagnosis. We traditionally associate violence with a number of diagnosesschizophrenia, mania, sociopathy, conduct disorder (in children and adolescents), intermittent explosive disorder, and substance use disorders (especially when a person is actually using drugs or alcohol). However, the overwhelming majority of mental patients do not perpetrate violence. In fact, a major Axis I mental disorder such as bipolar I disorder or schizophrenia (Brents diagnosis) carries a lower risk of violence than do some personality disorders. A number of physical brain diseases can also lead to violencehead injuries, seizure disorders, Alzheimers and other dementias, infections, cancer and other mass lesions, toxicity (including drug and alcohol), and metabolic conditions. The comorbid diagnosis of substance misuse is always important to watch for. Gender. Men are traditionally regarded as committing the major share of violence. However, among mental patients, women like Brenda are about as likely to perpetrate violence as men, though their victims may be less likely to require medical attention. Violence in women occurs most often in the home. Previous violence. A history of violent behavior is a traditionally strong predictor. Remarkably, learning about such a history doesnt usually pose a problem: patients are often quite willing to admit to prior offenses. Brendas prior history of conviction for assault clearly demonstrated her potential. Abuse. Childhood physical (but not sexual) abuse is positively associated with later violence. Antisocial personality disorder. The risk of violence is greatly increased in patients with ASPD. Although wed need more information to be sure, what we know so far about Brenda should alert us to the possibility of conduct disorder and ASPD. Hallucinations. Command hallucinations that order the person to commit violent acts increase the risk; other hallucinations are not related. Other delusions (Brent thought he was the Antichrist) do not predict violence.

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Anger and thoughts/fantasies of violence. Ideas of violence beget violent behavior. Brenda was clearly signaling her intentions. Age. The time of violence, like the time of love and procreation, is youth. No surprises here. In summary, the actuarial model predicts that violent mental patients will tend to be those who are young, hostile, misuse drugs, and have a history of previous violent behavior. And it would be Brenda, not Brent, who represents the greater risk. Numerous studies report that discharged mental patients are likely to perpetrate violence only if they use substances. Unfortunately, they are more likely than the general public to misuse substances. When mental patients do repeat violence, it is usually within a relatively short time after hospital discharge. Heres a final, sobering thought: some of the most notorious violent patients in history would probably have slipped past the best of our current predictors: Prosenjit Poddar (who murdered Tatiana Tarasoff, eventually leading to the recognition of a duty to protect known as the Tarasoff principle); Mark David Chapman (who killed John Lennon); and John Hinckley, Jr. (who attempted to assassinate Ronald Reagan). Each of these individuals had had intense fantasies, but no prior history of violence. Even the best research and instruments can currently deliver no promises, only predictions. Table 6. Criteria for psychosis (DSM-IV simplified) Duration Symptoms
6 months or more Schizoaffective Schizophrenia disorder At least 2 of: Delusions Hallucinations Disorganized speech Disorganized behavior Negative symptoms At least 2 of: Hallucinations, Delusions, Disorganized speech, Disorganized behavior, Negative symptoms, plus Simultaneous major depressive, manic or mixed episode At least 2 of: Delusions Hallucinations Disorganized speech Disorganized behavior Negative symptoms

Disability/Severity
Material impairment in patients work, socialization, self-care

Exclusions
Mood disorder Schizoaffective Gen med condition Substance-related Developmental disorder Gen med condition Substance-related

1+ month of sx (less, if treated). For 2 weeks, delusions or hallucinations w/o prominent mood sx 16 months

Mood episode symptoms present during substantial part of active and residual portions of the illness

Schizophreniform psychosis

With good prognostic features if 2+ of: Psychosis starts w/in 4 wks of onset Confusion or perplexity Good premorbid social, work functioning Affect not flat, blunt

Mood disorder Schizoaffective Gen med condition Substance-related

Brief psychotic disorder

One day to one month, with full return to previous functioning level

1+ of: Delusions Hallucinations Disorganized speech Disorganized behavior Delusion is similar in content to the first persons delusion

Mood disorder Schizophrenia Schizoaffective Gen med condition Substance-related Mood disorder Schizophrenia Schizoaffective Gen med condition Substance-related

Shared psychotic disorder

Begins after a close associate becomes delusional

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Review
When he was 17, Jasons parents (and two other adults) took him to the hospital. Late at night, when he was alone, he had been hearing the voice of his Spanish teacher. Her voice, which seemed entirely real to him, told him (in Spanish) that he had been selected to be sacrificed. With increasing frequency, for nearly a year, he had heard the voice, and he was becoming more and more frightened. His mother heard him pacing his room at night, but when she asked what was wrong, he would shrug and silently turn away. The day he was admitted, she had entered his room to straighten up and found it completely destroyed. The shelves were bare; all their contents had been piled in front of the wardrobe door. His clothes had been dumped from the dresser and shredded with the scissors he had then used to inflict dozens of tiny wounds on his forearms. Sensitive and friendless as a little boy, Jason had never shown the slightest interest in other people. Instead, he developed such a passion for moths and butterflies that by the age of 13, he had collected several hundred varieties. Before becoming so ill, he had often studied the wonderful collection at the natural history museum. He even thought that he had discovered a new variety of Papilio polyxenes, the black swallowtail butterfly. However, he hadnt chased a butterfly in weeks, and his only scientific activity had been talking into his portable tape recorder. His family life had been marked by the divorce of his parents several years earlier. Each of his parents had subsequent lovershis mothers current boyfriend lived in their home, but so did his father. An aunt had had a breakdown when she was in college and never recovered; she had lived with her parents until she died, an eccentric and lonely woman. Jasons doctor started him on Haldol, which quieted the hallucinated voices and calmed his agitation, but a few weeks after leaving the hospital he stopped taking it. He told his mother that it made him feel wired and he didnt need it anyway; he wasnt sick. For several weeks he just seemed anxious and irritable, then he gradually became aware that his telephone conversations were being intercepted, and he thought that the museum curator was trying to steal his P. polyxenes. On his second hospital admission, the doctor asked whether he could be mistaken about the curator. Jason just gazed out the window. His appearance showed evidence of neglect. His jeans were stiff with dirt, and he needed a wash himself. He sat sullenly, arms folded across his chest. Later, his mother brought in his little tape recorder. On it, Jasons voice said this: I think I have developed a new construction of a P. polyxenes. This construction is built largely on a podel that mitigates its life force. When asked about the word podel, he said that it was a model of a P. polyxenes. 1. 2. 3. 4. 5. Write out a complete differential diagnosis for Jason. [p 71] Which basic symptoms of psychosis did Jason have? [p 70] Which basic symptoms of psychosis did Jason lack? [p 70] What would be your best diagnosis? Justify your choice. [p 73] How would this change if Jason had been ill for only 3 months? [p 80]

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6. How would you describe Jason as a child? And how could this relate to his diagnosis as an adult? [p 73] 7. Outline your treatment recommendations for Jason. [p 77] 8. What indicators of risk for violence does Jason have? Which does he lack? [p 85] 9. To receive the diagnosis of schizoaffective disorder, what would Jasons symptoms have to be like? [p 79] 10. Suppose Jason had had only delusions and no other psychotic symptomshow might this have altered the course of his illness? [p 81]

Further Learning
There are an awful lot of books on Amazon written by people who claim to have recovered from schizophrenia. I tend to look askance at most of these, because I have trouble being sure that they were properly diagnosed in the first place. One resource that I can recommend is the movie version of A Beautiful Mind. It gives the viewer a really good feel for what it must be like to experience psychosis. Readily available on DVD. Popular writers do seem to have discovered delusional disorder, at least that form of it called erotomania. Quite a few years ago the movie Fatal Attraction starred Glenn Close in a virtuoso portrayal of a person who was obsessed with the belief that Michael Douglass character was in love with herto the point that she arose from what appeared to be death in a bathtub of water to renew her attack. (Never mind that women with this disorder arent usually the ones who are violent.) More recently, Ian McEwen wrote a gripping portrayal of the disorder in Enduring Love. Its a great read that in 2004 was also made into a motion picture.

Chapter 6

Anxiety and Panic

In its many forms, anxiety has emotional, mental, physical, and behavioral effectsan uneasy sense of apprehension; a decreased ability to concentrate with a nagging sense of unreality; nameless fear of death orthe unknown; heart palpitations or chest tightness; dry mouth or trouble swallowing; nausea and hyperventilation. Anxiety can be felt as irritability or fear, which can produce a powerful urge to lash out or to run. Anxiety can also take the form of chronic worry, as if by ruminating about the future we can sometimes control it. Everyone feels some of these anxiety symptoms at one time or another, perhaps before a public performance or when confronting some other unpleasant task. When brief and relatively mild, anxiety is a natural, normal reaction to a perceived threat. It is useful: it signals us to watch for possible danger, it sharpens the senses to help us prepare for upcoming tests or performances, and it reminds us to stay on the right side of the law, moral codes, and professors. But problems arise when anxiety becomes too intense or lasts too long. Then, instead of spurring us to run the race of our life or ace an exam, it muddies our thinking and robs us of focus and alertness. So, anxiety is a little like food: sometimes its hard to judge how much is too much. With a conservatively estimated 20% lifetime risk, anxiety disorders are the most common of all mental disorders. All occur more frequently in women than men, a finding that has researchers worldwide scratching their heads. Most anxiety disorders seem to run in families and have some genetic basis, but heredity alone cant explain them: lifes events and circumstances also play powerful roles. All anxiety disorders have in common one or more of the following features: Anxietyan uneasy state of apprehension that exceeds any actual threat you may be facing Panicacute anxiety accompanied by bodily symptoms such as racing heart, trouble with breathing, and uncontrollable trembling Phobiaanxiety where you can pinpoint the cause, which exceeds any actual threat Stresswhich causes anxiety (or fear)

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Panic Disorder and Agoraphobia

The riveting anxiety of a panic attack creates a characteristic pattern of incapacitating physical symptoms. Everyday panic (I panicked when I locked my keys in the car, The Dows drop signals panic in the markets) pales in comparison. True panic attacks can so flood the intellect that we cannot focus our attention, even on issues so important as examinations, promotions or sex. Now age 31, Winfields first panic attack had occurred about 5 years earlier when he was flying to Europe on vacation. They had just cleared the U.S. coastline when he suddenly felt he was about to suffocate. His chest hurt, his heart pounded, and he thought he was on the verge of a true, personal disaster. His head seemed to bob and spin, and his hands trembled so that he couldnt eat his meal. The woman next to him kept pulling away like she thought I was crazy, but a man sitting behind him suggested that he breathe into a paper bag. He survived the trip with his face buried in an air sickness bag. When he arrived in Paris, he felt overwhelming anxiety whenever he left his hotel room, which was where he remained for most of a week, venturing out only for meals and a quick trip to the Eiffel Tower. After he returned home he had no recurrences for several months until one evening at a concert he realized that he was sitting in the middle of the second row: once the music started, he would be trapped. Again, everything seemed to be closing in around him; he expected that he might die or lose his mind. The next day, he consulted his general physician, who said his health was good and minimized the problem. Lately, Winfield has had frequent attacks, especially when in a crowded place like a shopping mall or a football stadium. Just the thought of attending a concert is enough to cause intense anxiety, so he avoids crowded places and spends most of his time at home. He mostly telecommutes to his job as an accountant, but he cannot even go for a drive without experiencing severe anxiety. When he must shop for groceries, he asks his brother a neighbor to go with him.

Symptoms and diagnosis

Winfields symptoms include trouble breathing, chest pain, heart palpitations, dizziness, tremor and fears of calamity; other people complain of faintness, sweating, numbness or tingling of their hands, hot and cold flashes, or feelings of unreality. During a typical panic attack, patients will experience several of these symptoms and have a foreboding sense that some disaster is imminent. Some attacks are cued by a stressful event, such as seeing a spider or hearing the sound of gunfire. Uncued attacks come out of the blue, with no known precipitant. Some people have both types of attack. The complete list of panic attack symptoms is given in the footnote to Table 7a. Typical panic attacks start suddenly and build rapidly to a peak. The entire episode lasts less than half an hour, though it can seem a lot longer if youre afraid that you are going crazy or your hearts about to explode. Severe panic attacks sometimes cause repeated trips to an urgent care center or emergency room. If you were suddenly attacked by a dog or you realized your 2-year-old was missing from the backyard, it would be perfectly normal to feel these physiological symptoms. However, repeated severe panic attacks, cued or uncued, interfere with social and interpersonal lifea student may

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find it impossible to move out of the parental home, a spouse may seek divorce. At a minimum, the breathlessness and weakness can force the person to lie down or otherwise interrupt the normal routine.

Agoraphobia: often added to panic

Panic attacks often occur in agoraphobia, the fear of being in a situation from which escape isnt possible, or where help might not be available if anxiety symptoms develop. The agora is a Greek marketplace, but people with agoraphobia are likely to avoid any venue where theyd have difficulty making a speedy exit, including malls, buses, bridges, theaters and travel away from home. Like Winfield, these people run a severe risk of becoming housebound, so fearful are they to leave home that they simply dontor else, they travel only when escorted by a trusted companion. Even to them, the fear seems irrational, and they may think they are going crazy. And like Winfield, agoraphobia often seems to start with a panic attack. When out and about, a panic attack occurs that is subsequently forgotten. However, these people begin to generalize fear to other situations that involve being away from home. Agoraphobia without actual panic attacks may be more common than we once thought, affecting perhaps 3% of the general American population. Possibly, only those with panic come in for treatment; those whose only complaint is agoraphobia just stay home. In any event, when it comes to making the final, formal diagnosis, the choices are panic disorder (PD), agoraphobia, and PD with agoraphobia. In Table 7a, you can see exactly how the criteria differ.

Differential diagnosis
Anyone who has ever experienced a panic attack will feel that something is wrong, but one attack doesnt always mean there will be more. Many young people have a few episodes of panic without ever developing a lasting pattern of repeated attacks. For some, isolated panic attacks may be just one more youthful rite of passage. But when panic attacks are repeated over and over, the first step is to rule out medical illness as their source. Panic attacks are rarely caused by thyroid disease, infections such as pneumonia and Lyme disease, low blood sugar, certain types of heart disease, chronic lung problems such as emphysema, or pheochromocytoma. In the past, physicians have often regarded mitral valve prolapse as the cause for panic attacks. More recently, however, weve concluded that, when the two coexist, both should be diagnosed. A medical condition is a somewhat more likely cause of panic attacks if they begin after the age of 30, if they have begun only recently, or if there are unusual symptoms such as trouble walking, an altered level of consciousness, or loss of bladder control. Attacks can also occur with the excessive use of certain drugs, including caffeine, marijuana, and amphetamines. PD remains the most likely diagnosis for recurrent panic attacks, which can occur occasionally or many times a week. It isnt unusual to awaken at night with them. For weeks, they may come in daily wavesthen calm for months. The prospect of more attacks occurring any time, unexpected and unexplained, would worry anyone. People will do nearly anything to avoid them. Following is a reasonably complete listing of the conditions you might consider in a person who is experiencing symptoms of panic:

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Anxiety due to substance use Anxiety due to a medical condition Major depression Specific phobia Social phobia PTSD OCD Anorexia nervosa

Epidemiology, etiology, and comorbidity

Women are twice as susceptible as men to panic disorder, but no one knows why. It runs in families and is at least partly genetic, though many clinicians also believe that we learn to have panic attacks through behavioral conditioning. Still others implicate loss of parents in childhood and loss of important adult relationships as possible psychodynamic causes, but no one really knows for sure. We do know that no racial or ethnic group is immune, that panic disorder usually begins in the late teens or 20s, and that it is more common than you might expect, affecting perhaps 3% of all adults. Major depression strikes a large proportion of PD patients (over half in some studies); indeed, often the mood disorder begins first. Their coincidence is frequent enough that it is important to look for mood disorder in any patient who presents with any anxiety disorder. Some people try to control panicky feelings by overusing alcohol or drugs, prescribed or otherwise. Other anxiety disorders often accompany panic disorder, including generalized anxiety disorder (GAD), social phobia, obsessive-compulsive disorder (OCD) and posttraumatic stress disorder (PTSD). Panic disorder is present in at least half the people with agoraphobia, and depression and other anxiety disorders are also common with agoraphobia. In their quest for relief, many also turn to the use of drugs or alcohol.

Treating panic and agoraphobia

The folk remedy of breathing into a paper bag, which forces rebreathing of carbon dioxide, can relieve symptoms of panic. However, experts now recommend against it, for the simple reason that it could exacerbate some conditions (asthma, heart attacks) that entail shortness of breath. Nonetheless, for actual panic attacks, reassurance from a physician could be all the treatment some patients need to prevent further episodes. For actual PD, the recommended treatment will depend on the severity of attacks and the presence of other disorders, such as depression. Winfields doctor approached his PD from several angles, beginning with some education. He felt reassured when he learned that he didnt have a serious physical disease, but a wellknown condition that thousands of others had successfully conquered. He was instructed to avoid using nicotine and caffeine, which could worsen his panic attacks. He started taking an antidepressant, the SSRI citalopram (Celexa), at the very low dose of 5 mg/day, increasing by 5 mg/day each week until he got to 20 mg/day. Several weeks after beginning his treatment, he noticed that he hadnt had a panic attack for days. This

Anxiety and Panic wouldnt have been especially noteworthyhe had sometimes gone for weeks at a time without onebut always before, they had seemed to tail off gradually. This time, as he told his therapist, it was as if they had packed their bags one night and sneaked away.

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Most physicians would probably recommend one of the SSRIs, which work well for panic disorder and produce relatively few side effects. If the first SSRI fails, try a different one, venlafaxine (Effexor), or a tricyclic antidepressant such as desipramine (Norpramin). For lingering anxiety symptoms, they might add a beta blocker such as propranolol (Inderal). Monoamine oxidase inhibitors are usually reserved for those who dont respond to other drugs. As with so many other mental disorders, the most frequent cause of non-response is taking too little medication. But PD patients tend to be sensitive to the side effects of antidepressants, which can initially exacerbate agitation. Thats why Winfield started with less than half the usual dose. The period of hypersensitivity usually lasts a week or two, after which the dose can be gradually increased until symptoms remit. Other medicines that have been used to treat panic disorder are more problematic. The risk of tardive dyskinesia should completely eliminate traditional antipsychotics. The antianxiety agent buspirone (BuSpar) is ineffective in treating panic. Of the benzodiazepines, only alprazolam (Xanax) has good evidence for effectiveness at reasonable doses, but some people have trouble stopping it. Even if medications block the actual panic attacks, patients often continue to experience anticipatory anxiety and avoidance behavior. Thats why many physicians also recommend psychotherapy, which can provide help with symptom control right away and later help bridge the period of drug discontinuation. Cognitive-behavioral therapy (CBT) specifically targeted at panic symptoms is at least as effective as medication, and the effect may last longer. One behavioral component is to retrain breathing, so as to control the hyperventilation that occurs with panic attacks. The acute phase of treatment should last about 12 weeks. Once improved, no one knows for sure just how long treatment should last, so most patients should probably continue the antidepressant for 1218 months before attempting to taper it. Relapses arent uncommon; they indicate restarting medication. Treating agoraphobia Within a few weeks, Winfields panic attacks had subsided a lot but, fearing another attack if he went out, he remained nearly housebound. At that point he was referred to a therapist, who urged him to join a group of agoraphobia patients for direct exposure treatment. They made lists of what bothered them the most and ranked the items in order of increasing anxiety. Then they went out in small groups to face their fears. After the first couple of sessions, one group member reported marked improvement and dropped out, but the others continued for 12 weeks. By the end of these sessions, most had improved. In addition to the group therapy sessions, Winfield went out each day by himself, even though it initially caused him to feel shaky and frightened all over again. By the end, he could go shopping alone and attend theatrical performances once again. Most people who are treated with exposure therapy experience reduced anxiety, improved morale, and greater ability to form relationships and pursue work and leisure interests. However, anyone who cannot use the exposure approach may derive help from other treatments, including

Anxiety and Panic cognitive-behavioral therapy, assertiveness training, meditation, and relaxation. Other than managing associated panic attacks, drugs are not generally indicated for agoraphobia.

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Course of illness
Although most people seek treatment soon after the first attackpanic is just too uncomfortable to tolerateleft untreated, many follow an on-off pattern of symptoms for years. They may experience frequent attacks for weeks on end, yielding to weeks or months with essentially no episodes at all. Self-medication with drugs or alcohol or refusal to leave home can have serious implications for work and social life. Well over half those who complete treatment are recovered or very much improved. Only about a quarter still have symptoms severe enough to require a trial with other therapies. Prognosis is better if symptoms have been present for just a short timeanother excellent reason to begin treatment as soon as the diagnosis has been made.

Sidebar: Talking to Patients About Stress

What can I do about all the stress Im having? is a question psychiatrists and other doctors are likely to hear. It helps somewhat to have a good suggestion or two ready; it helps more to have an organized list of answers. It might go something like this: Theres a complicated relationship between anxiety and stress: stress can cause anxiety (and other illnesses, both mental and physical), but anxiety is also a symptom of stress. There is powerful evidence for some of these causal relationships, such as when a hard workout immediately precedes a heart attack or job loss leads to depression and anxiety. However, environmental factors can modulate the effect of stresssomeone with no money in the bank may feel more keenly the loss of a job. These intertwining relationships between stress and mental disorder provide one motivation to reduce stress in our lives; but many people without diagnosable mental disorders are affected by stress. Of course, we often have little control over many of lifes most stressful eventsthe death of a relative, severe illness, being downsized in a recession and, sometimes, pregnancy. Even so, there are steps you can take to help reduce the toll stress takes on your health and happiness. And when our best efforts at prevention fail (as they inevitably will, from time to time), youll find a few suggestions for keeping a lid on anxiety. Make a list of all your tasks. Having each source of stress written out in black and white can help give you a sense that you can get your arms around your burdens. Practice time management. In simple terms this means: (1) prioritize your list, putting the most important tasks first, (2) estimate the time needed for each (add about 10% to each as a cushion), (3) search your calendar for blocks of time for each task, (4) match your tasks to the block available (maximizes efficiency). For each problem you face, be sure to include all your possible solutions, even if your principal alternative is do nothing. The feeling that you have no options creates a sense of helplessness and anxiety. Interrupt your usual routine with something you dont have to dolistening to music, reading for pleasure, taking a shower or warm bath, talking with friends. Giving yourself time to pursue a pleasurable activity is a reward that can quickly recharge your batteries.

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Even with just seconds available, think about something pleasurable you have done lately or would like to do. Keep regular hours. Nothing stresses the system like pulling an all-nighter. Spend time out of doors. Daylight improves mood, fresh air is bracing, and communing with nature (even in an urban setting) helps maintain perspective. Eat several small, well-balanced meals each day. Avoid eating at your desk, and try not to discuss work at mealtime. Studies show that just talking to a patient about such matters as diet and smoking can help them gain control over weight and nicotine. I worry that too few doctors bother. Exercise for at least an hourpreferably moreeach week. Nothing helps you through tough times like knowing what to do; establish routines (but brace yourself for change, when its needed). People feel perkier when they are well-hydrated, so drink plenty of liquids (but keep alcohol, coffee, tea, and other psychoactive beverages to a minimum). Practice regular breathing exercises, but avoid hyperventilating. Ventilate your frustrations to anyone who will listen, but share your triumphs with someone you love.

Specific Phobias
Agoraphobia is just one of many phobias, the general definition of which is a fear of some situation or object that far exceeds any real threat. The fear is normal if a poisonous spider crawls onto your pillow. But if you encounter a Daddy Long Legs on a wall, it isnt normal to have a panic attack and refuse ever again to enter the basement. To feel anxiety if trapped alone in an underground cavern is reasonable, but a full-blown panic attack whenever crossing a bridge isnt. When imagination makes something benign seem so ominous that fear significantly restricts their behavior, people are diagnosed as having one of three types of phobia: specific, social, and agoraphobia. Well cover the second of these later (page 107).

Symptoms and diagnosis

With phobias, the threat is something you can identifysuch as snakes, heights, or dentists. When confronted with the feared stimulus, people may respond with a panic attack, though it could also be just a feeling of intense anxiety or dread, without the physical symptoms typical of panic attacks. Many years ago, before we had effective treatments for phobias, about all mental health professionals could do was to pretty them up with Greek or Latin names. There are over 250 of these, hardly any of which are used anymore. In fact, people can develop a fear of just about anything (Lemony Snickets character, Aunt Josephine, had a morbid fear of real estate agents). Besides agoraphobia, the two names youll still encounter are acrophobia (fear of heights) and claustrophobia (being closed in). Specific phobias are what most people associate with the term phobiawhen someone needs comfort during a thunderstorm or dissolves into tears upon spying a mouse. Anticipating harm, embarrassment, or other dire consequences, the person becomes frightened the moment the feared thing appears, perhaps when it only creeps into consciousness. Some people have

Anxiety and Panic multiple phobias; for example, composer Richard Rogers feared almost anything having to do with travel, including bridges, elevators, and tunnels. Andreas fear of flying started on a return flight from a European meeting. High winds buffeted the plane; while landing, she had a clear vision that they would be caught in a wind shear and crash. Although she continued to fly, her misery grew with every business trip. Beginning several days before each flight, she would feel terribly anxious; her heart banged along something fierce and sometimes skipped beats. Whenever she stopped to think about an upcoming trip, she had trouble breathing and felt weak, dizzy, and out of control. Terrifying thoughts about crashing or being hijacked kept her from concentrating on her work. Her anxious thoughts would come in waves and increase over several days until they peaked on the day of her trip. She had never failed to complete a flight, but it required an almost superhuman force of will. Once, she had taken a course in which she was encouraged to meditate and visualize successful flying, but it didnt seem to help. She had also tried several medications and self-hypnosis, but she remained fearful. I know its way out of proportion, she said, but job or no job, I dont think I can survive this way.

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As with other phobias, fear of flying presents a spectrum of distress. Some people feel only mildly nervous; others call themselves white-knuckle flyers who will travel by plane only as a last resort. Even then, it may only interfere with vacation plansafter all, you can always go by car and avoid visiting other continents. A few refuse to fly for any reason, creating problems at work or in their personal or social lives. Andrea seemed to be heading in that direction. Rather common, fear of flying is one of the situation phobias; other examples are riding in elevators and driving across bridges. Besides situations, people can have three other classes of phobia: animals, conditions of the natural environment (thunderstorms, heights, water); and injury or blood (needles, visits to the doctor). A few other phobias are harder to classifythe fear of getting sick, for example, or, in children, fear of clowns or other costumed characters. Many people have more than one phobia, which are usually of the same type, such as snakes and spiders. Many people dont fear the thing itself but the imagined outcome. For example, Andrea would be perfectly happy to be near an airplane, if she knew she didnt have to board it; what she feared was that a plane would crash with her on it. Those who are afraid of heights visualize a fall; those with spider phobia worry theyll be bitten. A woman who feared crossing bridges worried that an earthquake would strike while she was on one and hurl her into the chasm below. These fears are not only excessive but persistent and unreasonable (logic doesnt resolve them). Differential diagnosis Anxiety due to substance use* Anxiety due to a medical condition* Major depression Panic disorder Agoraphobia Social phobia PTSD
Although specific phobias are not usually associated with substance misuse or with physical illnesses, these two categories belong at the top of every differential.
*

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Epidemiology, etiology, and comorbidity

Phobias often begin in childhood or the teen years and almost always start by the age of 25. A fairly strong hereditary component has been identified, but many experts today will tell you that they probably come about when something acts as a trigger in a person with genetic vulnerability. Several circumstances can set up that trigger: direct experience with something that subsequently causes fearfulness (a child being terrified and alone in a thunderstorm, for example); seeing someone else react fearfully to storms; even hearing about someone who has been struck by lightning. When a subsequent lightning storm pulls the trigger, the intensity of reaction may be influenced by degree of physical proximity to the feared object and how hard it is to get out of the way. Specific phobias are common, affecting perhaps 10% of us at one time or another; they are more common in women. Animal phobias typically begin in childhood, but most others begin in adolescence or early adulthood. They are more likely to occur in people who have witnessed trauma, been confronted by an animal, been warned repeatedly to beware certain objects, or been trapped in situations such as a small room. These can begin suddenly or gradually, then intensify. Unless treated, most are likely to continue indefinitely. Commonly comorbid conditions include other anxiety disorders, mood disorders, and substance misuse.

Treating specific phobias

Many people successfully cope with a specific phobia by just ignoring it. That isnt hard to do if it is mild enough, but then, most clinicians probably wouldnt dignify it with the term phobia. Living someplace where you wont encounter the stimulus is another coping strategy. For example, city dwellers dont meet many snakes (of the sort that slither, anyway), and Oregonians dont have to endure many thunderstorms. In fact, most patients seek treatment because of something else entirelyoften, a comorbid condition. However, certain phobias demand resolutionfor example, the person who lives or works in a skyscraper and is afraid to ride an elevator above the second floor. The most efficient (if traumatic) treatment would be direct exposure, also called exposure in vivo. A therapist might at first walk the patient to an elevator in a three-story building and just stand there talking for whatever time it takes for the anticipatory anxiety to subside. Next, both patient and therapist might step inside, with the door open. Riding to the second floor would be the next logical advance, then to the third floor, pausing at each step long enough to allow any anxiety symptoms to climax and subside. Many sessions might be necessary before the patient could comfortably take elevator trips alone to the top of tall buildings, but once attained, that mastery would probably be permanent. Direct exposure is also useful for fears of driving, crossing bridges, and other specific phobias. It isnt practical for thunderstorms, which are hard to schedule. Then, CBT and other techniques can be used, depending on the feared stimulus, the patients willingness, and the therapists judgment. With systematic desensitization, the patient imagines scenes progressively

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more anxiety-provoking until at last, perhaps after many sessions, tolerance for all aspects of the feared stimulus is achieved. Other than managing associated panic attacks, drugs are hardly ever a useful main treatment for specific phobias. However, a low-dose benzodiazepine or a beta blocker such as propranolol might be useful to reduce anxiety right at the start of exposure treatments.

Special Case: A Needling Anxiety

Medical personnel especially need to know about fear of needles, which affects a persons physiology atypically. When people with needle phobia encounter needles, they dont get the usual adrenaline surge. Rather, heart rate slows and blood vessels relax in their extremities, yielding a falling blood pressure, with sweating, nausea, and lightheadedness; sometimes they faint. Occasionally, the loss of blood pressure leads to a heart attack or a fatal arrhythmia. A number of approaches to needle phobia are currently used. If relatively mild, lying down with legs elevated when having an injection or blood drawn may prevent fainting; breathing slowly to prevent hyperventilation may also help. Some people find relief in antianxiety drugs taken before a procedure. Rubbing a local anesthetic cream onto the spot a few minutes before the needle stick can reduce pain and anticipatory anxiety. Iontophoresis (a $400 gizmo that draws a local anesthetic into the skin, allowing painless penetration) has worked very well for some patients. Although some people are helped by systematic desensitization, it should only be undertaken in or near a doctors office, where medical help can be quickly available. No one knows just why some people respond so strongly to the prospect of a needle stick. Its physiological underpinnings and the fact that it seems to run strongly in families suggest that this condition is quite different from other specific phobias. The consequences can be dire: the medical literature reports death in a score of patients; 5% or more of Americans avoid essential care because of it. In the case of needle phobia, there is more to fear than fear itself.

Social Phobia
Shyness and stage fright plague many of us, but some people feel so uncomfortable in social situations that they dread leaving home, meeting anyone new, or speaking with anyone but close relatives. Gordon started an antidepressant at 24 when he became clinically depressed. Although his mood improved dramatically, he noticed that he had started blushing again. He had first noted this problem years ago in speech class, when he was only 16. He was supposed to give a 5-minute talk about his hobby, stamp collecting. The very thought of getting up in front of the class dried his tongue like a flannel cloth. He couldnt utter a word, and his muscles twitched and he shook so hard he felt glued to his chair. Even if I could have spoken, I couldnt have physically gotten up to make a speech, he told his doctor, years later. He was supposed to debate a few days later but, terribly self-conscious, he stayed in bed that day. He did well on all the tests but earned only a C-minus in the class because he hadnt given any speeches. The grade was a gift, he admitted. Other social situations began to cause Gordon terrible anxiety. Even a simple, formal introduction made him blush or stammerhe eventually took a job writing ad copy so he could work in a cubicle and not meet people. He stopped attending football games, because

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he knew hed have to use a urinal when other men were waiting behind him. He was especially leery of his boss; though he admitted that she was a very nice person, Gordon tried to be out of the office when she came around. If he ever met someone he knew from work, hed avoid eye contact so he wouldnt get trapped into making small talk, which always left him feeling ignorant and flustered. He liked women and wanted to date, but the thought of asking someone out made his knees buckle. I know this is stupid, but Im afraid Ill look like a nerd.

Symptoms and diagnosis of social phobia

Social anxiety* patients are withdrawn and shy with strangers, and may not speak up in groups. Although they like other people and want to be with them, the presence of others induces marked physical and emotional symptoms such as palpitations, perspiration, tremors, fearfulness, and poor concentrationthe very stuff of panic attacks, though the symptoms may constitute only nonspecific anxiety. Typically, these patients are highly self-critical and have low self-esteem; so as not to appear dull or dumb, they avoid situations where they must socializewhich can make them seem standoffish or elite. Some blush or avoid eye contact. So, one person may feel disgraced in a business meeting; another is intentionally late for a new course in school rather than meet new classmates; a third cant go to a party for fear of appearing an idiot on the dance floor. Like Gordon, people with social phobia often feel as though all eyes are trained on them to detect their smallest mistakes. They experience their distress most acutely with strangers, though some anticipate danger in every social situation. One woman likened her social phobia to wearing a sheer dress that barely concealed her nakedness yet offered neither warmth nor protection from the gaze of others. These experiences cause far more distress and disability than garden-variety shyness. Indeed, we wouldnt diagnose social phobia unless it materially impairs the individuals life or causes a great deal of distress. (Gordons discomfort with urinating in a public restroom, sometimes called paruresis, or shy bladder syndrome, is relatively rare, and may even have origins different from other types of social anxiety.) Fear of public speaking (mike fright) is the most common of these social anxieties; other situations include meeting people, eating in restaurants, using a telephone or public restroom, even writing when others are watching. The common thread is a fear of doing something that will prove acutely embarrassing. The feared situation causes intense anxiety, which can grow into a full-blown panic attack. Of course, these anxiety symptoms only lead to further embarrassment. The patient knows that these fears are irrational and hates the low self-esteem that follows such a social encounter. The anxiety of social phobia is attached to three points of behavior. Of course, there is the activity itself. If you have social phobia, you harshly judge your own social performances and view others in the same situation as being more capable than you. The result is poor performance, or at least the perception that you perform poorly. However, just the anticipation of the activity can generate automatic thoughts (Ill look like a complete idiot) that breed fear.

Some patients and clinicians cling to the older term social anxiety disorder, and may become huffy at the suggestion that it is anything like a regular phobia.

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And that generates the third point: Avoidance to reduce the anxiety. Someone who cannot avoid the activity entirely may try to blend in with the crowd or, upon speaking, does so only with much anxiety and later worries about the performance. Because both social phobia and agoraphobia are associated with places where people meet, you may wonder how to distinguish them. Being with people is what bothers the person with social phobia. Those with agoraphobia arent afraid of people; they just want to avoid places where there are a lot of them. A second issue of differential diagnosis: the criteria for avoidant personality and social anxiety overlap to the extent that many patients with one diagnosis have both; the former may ultimately be deleted from the diagnostic manual. Differential diagnosis Anxiety due to substance use Anxiety due to a medical condition Major depression Panic disorder Agoraphobia Specific phobia Normal shyness Body dysmorphic disorder OCD Avoidant personality disorder

Epidemiology, etiology, and comorbidity

Behind major depression and alcohol dependence, social phobia is the third most common mental disorder; lifetime prevalence is around 5%, possibly more, depending on the study. Its onset is usually in adolescence or young adulthood50% by age 11, 80% a decade later. Once begun, it tends to develop slowly, though occasionally an embarrassing social event abruptly precipitates it. As with other phobias, no one knows exactly what sets it off, though it often runs in families. Some sort of genetically transmissible trait such as low extraversion may make people susceptible to social anxiety (and other) disorders. Indeed, one Norwegian study found a common genetic influence for social phobia and avoidant personality disorder. The neurotransmitter dopamine may play a role in determining social phobiasas suggested by response to MAOIs, which act on dopamine, and by fMRI data, which find that these patients have reduced dopamine receptor sites and transporter binding. Social phobia patients also tend to have other fears: about half have agoraphobia, 60% have specific phobias. One in five abuses alcohol, perhaps to combat the anxiety and, like Gordon, one in six has major depression. Two studies have reported a strong association between social phobia and premature ejaculation (the social phobia comes first). Parkinsons patients have elevated rates of social anxiety disorder.

Treating social phobia

A patients treatment plan will depend on the severity and extent of the social phobia, as well as the presence of other disorders. For someone who fears many different social encounters, you should probably use both drug treatment and psychotherapy, though perhaps just one at a time.

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For many with social phobia, the SSRIs work just fine. Though double-blind studies have shown that monoamine oxidase inhibitors (MAOIs) are the most effective medication, their potential for side effects and the diet they require usually put them out of the running for first choice. For those who do use, say, phenelzine (Nardil), the response rate is over 50%, though it may take up to 90 mg/day for 6 weeks or longer to reach full benefit. Some people need medication long-term; others, just long enough to get started with CBT. The countless people whose only difficulty is performing in public or giving a speech may find a beta blocking agent such as propranolol very useful. Even some professional speakers and performers routinely use these drugs to reduce performance anxiety. Though there is little risk that such use will interfere with performance, the patient should avoid hidden surprises (such as excessive drowsiness) by trying a dose several days before the chips are down. For nausea or fear of vomiting, ondansetron (Zofran) works to prevent vomiting. Becoming depressed was luckier than Gordon realized, because it got him into treatment way under half of those with social phobia ever seek treatment. On paroxetine (Paxil), his depression had largely remitted and he felt less panicky at the thought of group CBT, the psychotherapy most often used. The therapist pointed out that a group approach allows the anxiety to be addressed in a social context, but also acknowledged that some patients need greater privacy when working on their social skills. Gordon discovered that the group could provide a model for his own behavior. It also provided feedback about some of his erroneous thinking, such as the belief that everyone could see how anxious he was. He learned to replace his automatic Id look like a nerd response with Id feel nervous, but I could still ask a question. To increase comfort in social situations, he and the other group members did some role playing and practiced initiating conversations and making small talk. Some members joined Toastmasters, and all were encouraged to consolidate their gains with homeworkfor example, making short speeches at dinner or reading stories to friends. Between therapy sessions, they were to practice on their own what they had learned during role playing. The group leader said that real-life practice is essential to the treatment, but that if someone didnt complete a homework assignment, it just meant that the assignment was too advanced and needed to be adjusted. Gordon felt especially successful when he invited a woman in his group out for lunch.

Course of illness
Although some people get along rather well overall because they fear only specific, avoidable social situations, they experience severe anticipatory anxiety when they must confront that special fear. Those who fear most social situations and feel comfortable only with close friends and family are said to have generalized social phobia; for them, phobic avoidance becomes a way of life. Untreated, they are more likely to remain isolated and unmarried, perhaps depressed and alcoholic, with limited capacity for work and interpersonal relationships. With available treatments, most social phobia patients will improve. Their anxiety may not be completely eliminated, but it should be reduced to a manageable level. Onset after age 11, advanced education, and absence of other psychiatric conditions all favor a good outcome.

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Generalized Anxiety Disorder

Lyman complained that he kept falling asleep at work. He had first been bothered by daytime sleepiness the year before, when he was still in college. Struggling to finish his senior thesis in psychology, he would stay up writing and revising until nearly midnight. Even then, he would lie awake for several hours, the tension mounting. I just couldnt seem to turn off the worrying, he later told his therapist. A year earlier, he had two important things to worry aboutfinishing his thesis and finding a job. Though he had managed to accomplish both, that hadnt stopped the worrying. Now Im worried about keeping my job, paying the rent, saving for retirement, and the economy. Last year seems like the good old days. The worry caused him to feel tense. Most days he noticed the knotted muscles in his neck; at its worst, he felt so agitated that he literally could not sit still. He had tried positive thinking and meditation, but when his mind seized on a worry, he found it nearly impossible to concentrate on anything else.

Symptoms and diagnosis

GAD has been used as a diagnosis for a little over 30 years, so a lot of research remains to be done. There are three important elements to this diagnosistwo that must be present, and one that must not. A typical GAD patient worries about many thingsjob performance, school grades, childrens health, finances, relationship with a lovereven such mundane matters as dry rot and leaky windows. Most of these worries will be personal, though some people fret about world hunger and the risk of earthquakes. These worries are hard to control and extremely durable, typically persisting despite abundant evidence that they wont come true. A healthy bank balance and stable job are no shield against worry about poverty. The pattern of worrying typically lasts for years, though the dominant focus may change from time to time. GAD is always accompanied by physical symptoms that include restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and trouble sleeping. Of these, the increased muscle tension is probably the most specific, but most patients have several physical symptoms. The third characteristic is the one that must not be present: there is no specific focus. The worries do not occur solely in the context of another mental disorder. If there is another anxiety disorder, as is often the case, GAD worries will go far beyond those normally associated with it. For example, those who also have a phobia will worry about many problems in addition to spiders or eating in public. A patient with panic disorder will have GAD worries in addition to the possibility of having future panic attacks. The problem isnt what the GAD patient worries about, but the worry itself.

GAD patients worry much of the time. As one man put it, Its all I ever accomplish. Worries keep them awake until long after bedtime or awaken them in the middle of the night. Although they usually maintain a normal work, school and social life, they may worry about how well they do with them and whether they can keep it up.

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Of course, worrying and anxiety dont always mean a diagnosis of GAD. In fact, most of us probably worry excessively at some time or other, often related to a specific situation: My mom is sick in the hospitalwill she pull through? You excel in the basic sciences, but will that success translate to clinical courses? We can worry about weddings or dinner parties, job security or dental appointments, and yet be perfectly normal. Such worries are expected, as long as they dont take over our lives, producing such physical symptoms and distress that we cannot function well in our jobs and personal relationships. Some clinicians remain unsure whether GAD is a genuine clinical entityperhaps it only indicates a basic trait of anxiety. However, patients usually realize that their worries are excessive, and they very much want to combat them. Differential diagnosis Anxiety due to substance use Anxiety due to a medical condition Major depression Somatization disorder Panic disorder Social phobia OCD Normal worry

Epidemiology, etiology, and comorbidity

Lifetime, around 5% of the general population will experience GAD, which often begins in childhood or adolescence, though it typically goes undiagnosed until much later. The prevalence rate increases with advancing age to peak after 40. Like most other anxiety disorders, GAD is no respecter of race or gender, though women are more susceptible than men. As with other anxiety disorders, GAD runs in families and probably has a genetic diathesis. It may get worse when the person is under stress; some women report more GAD symptoms before their menstrual periods. In addition to the usual associated anxiety disorders (such as PD and phobias) patients with GAD often have major depression, with the GAD coming first. Substance abuse is also sometimes an associated problem. There may also be physical conditions we associate with stress, such as headaches and irritable bowel syndrome.

Treating generalized anxiety disorder

Chronic worriers have typically been called worrywarts and advised to loosen up. Of course, it isnt that simple, especially if the worries fall into the GAD pattern. Its reasonable to start with an approach that can create permanent change. Two psychotherapeutic formats have been about equally successful: progressive relaxation and CBT. However, symptoms serious enough to produce intolerable physical or mental symptoms or to interfere with normal activities suggest the addition of drug treatment. Antidepressants have been shown to help the most, four of which have now been FDA approved for treating GAD: venlafaxine, duloxetine (Cymbalta), escitalopram (Lexapro) and paroxetine. If you need more antianxiety ammunition than the antidepressants can muster, buspirone produces less sedation than the benzodiazepines, and one study found that patients maintained

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their improvement better with it than with benzodiazepines. However, buspirone wont start working for at least a couple of weeks, so a benzodiazepine may be needed short term. All benzodiazepines are about equally effective. Because GAD patients often have depression as a more pressing problem, the antidepressant will often be effective for both conditions. Any substance use problems must be addressed forthrightly, either first or simultaneous with the GAD. Lyman began treatment with a form of CBT in which he was encouraged to practice progressive relaxation and to restructure the negative thoughts he was constantly having. Among other things, he learned he was supposed to replace his irrational thought I have too many problems to live with Oh, well, here comes one of those pesky worries again. Although he initially refused medication, after several weeks with little progress, he finally asked for something to take the edge off. He had tried an antidepressant a couple of years earlier and didnt like the way it made him feel, so this time he started on buspirone 5 mg three times a day and gradually increased the dose to 40 mg daily. Several weeks later he reported that he was feeling calmer and more confident. He now approached the CBT and progressive relaxation with renewed zest; within 2 months he could joke, Now I mainly worry how to pay for treatment.

Course of illness
To be candid, Lymans improvement may have been somewhat better than that of many patients. GAD is still too poorly studied to have confidence in predicting outcome. However, several studies have found that patients who complete these treatments maintain their gains for many months. Untreated, it will likely continue, perhaps with exacerbations and remissions, though half or more of affected people have only mild or moderate symptoms. Even with treatment, some symptoms may linger, especially if they are severe, but most patients will improve.

Posttraumatic Stress Disorder

If youve ever had a minor car accident, youve probably had some of these physical reactions: your heart beats fast, youre too weak to stand, you can hardly breathe. For days or weeks afterwards, the squeal of tires or honk of a horn brings back, just for an instant, some of the same anxiety you had after your accident. Some people who survive severe trauma develop symptoms that last much longerperhaps even a lifetimeand their symptoms are far worse than the aftermath of your car wreck. They have developed posttraumatic stress disorder (PTSD). As far back as the American Civil War, similar symptoms were identified in combat soldiers. Earlier names included shell shock and battle fatigue. Some of the same symptoms develop in survivors of other natural or man-made disasters, including airplane crashes, abductions, floods, rape, and terrorism. PTSD has even been identified in some heart attack patients.

Symptoms and diagnosis

Several months after her Army discharge, Aretta entered a VA hospital. While she was on duty at a military base in Germany, a master sergeant had raped her in the mess hall

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storeroom. Throughout the ordeal, he had clenched a knife in his fist; afterward, he threatened to kill her if she reported him. From then on, whenever she was assigned to KP in the mess hall, she tried to avoid the storeroom. If she had to enter it, her heart beat fast and her hands shook; invariably, she would cry. Several mornings, she went on sick-call because of a panicky feeling that her heart would beat right out of my chest, and she couldnt breathe. Then, she discovered that she was pregnant. Though closely questioned, she would never reveal the name of the sergeant who had raped her. Though she begged them, the military physicians had refused to perform an abortion, and her pregnancy earned her a general discharge under honorable conditions. Once she returned to her hometown to live, she paid for the procedure out of her separation pay. The abortion left her feeling empty and more guilty than I ever thought possible. Although Aretta had been told she could have her civilian job back, she never even telephoned her former boss. Returning to live with her parents, she spent most of the time alone in her bedroom. She reported that she just sat, because she couldnt really keep her mind on anything, even reading. She wouldnt talk to a friend who had enlisted with her, and she wouldnt watch a TV comedy about the army. On the rare occasions she helped her mother in the kitchen, she refused to use a knife; it powerfully reminded her of the afternoon she was raped. Aretta felt depressed and guilty (Though in my saner moments, I dont believe I led him on). She often had flashbacks, during which she felt the same fear and horror as on that day; sometimes she seemed to be living the rape all over again. It usually took her hours to fall asleep; several times she awakened screaming with a nightmare about being trapped in a sealed box. PTSD symptoms vary enormously with the individual, but four elements will always be present: Trauma. A wrenching experience, which might traumatize anyone, caused Aretta to feel threatened, fearful, and helpless. Re-experiencing. After a typical delay, she began to relive her experience, through bad dreams and flashbacks, and she trembled whenever she entered the storeroom. Avoidance. Aretta tried to avoid anything that reminded her of her experiencetalking with army friends, even using a knife. Some people develop amnesia for aspects of the traumatic experience. Arousal. Arettas severe insomnia and difficulty focusing attention on reading repeatedly demonstrated a state of high arousal. Others may startle easily or maintain an abnormally high degree of vigilance.

Many PTSD patients feel guilty: I should have done something to prevent it may seem irrational, but this attitude affects even combat veterans, who feel guilt and shame at surviving when friends did not. Like Aretta, many patients also experience depression, which is often important in selecting treatment. Delayed onset (6 months or longer after the trauma) of PTSD symptoms has been long reported, though it is unclear just how frequent this pattern occurs. Indeed, some clinicians apparently do not believe that such a pattern even actually exists. A 2007 review of the literature confirms the legitimacy of delayed onset, finding it in about 40% of military and 15% of civilian

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cases. There are suggestions that a delay in symptom development may be more likely in those who have suffered severe injuries or continued on deployment in a theater of combat. Differential diagnosis Anxiety due to substance use Anxiety due to a medical condition Major depression Somatization disorder Panic disorder Social phobia OCD Adjustment disorder Psychotic disorder

Epidemiology, etiology, and comorbidity

You wouldnt have to be hurt or even threatened to develop symptoms of PTSDwatching someone else die or sustain injury can provide the traumatic stimulus. Even hearing about something awful, such as a life-threatening illness in someone you know, can be traumatic. However, the more direct your exposure to a threat, the more likely you are to develop symptoms. In all, perhaps 5% of men and 10% of women have at some time had PTSD. The one-year prevalence of PTSD is as high as 8% lifetime, with women at greater risk than men. Of course, the prevalence will be much higher in VA mental health clinics. Older adults are less likely than younger adults and children to develop symptoms. In the case of rape, a history of childhood sexual abuse may increase risk of PTSD symptoms. Although not yet well studied, there are hints that genetics could play an important role. Why does trauma cause PTSD symptoms in some people but not in others? There are two sorts of reason, one tied to the trauma, the other to the person. Greater injury or threat to life both increase the risk of PTSD. Nearly a quarter of those who survive heavy combat will have symptoms, as will two-thirds of former prisoners of war. PTSD symptoms are less likely to follow forest fires, floods, and other natural disasters. Exposure to continuous or repeated trauma increases risk, which is why many schools curtailed videotape showings of the collapse of the World Trade Center after 9/11. On a personal level, the risk of PTSD increases with the degree of fear, helplessness, or horror experienced. The presence of a mood disorder or another anxiety disorder also increases the risk of PTSD, perhaps because of greater sensitivity to stress. It is increased in those who have less education and when the person senses a loss of family or community support. PTSD patients are likely to have other anxiety and mood disorders. In fact, VA psychiatrists find major depression to be quite usual among patients whose trauma is combat-related. Substance misuse is also highly comorbid.

Treating PTSD
PTSD symptoms are a conditioned responseinvoluntary behaviors learned during the course of the traumatic experiencewhich suggest that patients can unlearn them with psychotherapy or a behavioral technique. Many clinicians recommend a form of exposure therapy that forces one

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to confront, possibly in real life but more often through imagery, the events or thoughts reminiscent of the event. With sessions of virtual exposure therapy, they become able to face the situations that precipitate their symptoms. Arettas therapist asked her to describe the rape, as if it was occurring at that moment, and to report what she could see in her minds eye. It took some persuasion before shed even try; after her first attempt, she cried for the rest of that session. The following day, she felt more comfortable; after a few trials revealed that nothing bad would happen, her anxiety began to recede. To speed things along, her therapist encouraged her to practice confronting her fears just this way when she was alone. Sometimes, as in combat or concentration camp experiences, exposure may be too traumatic. Then, CBT is probably just about as effective at teaching new ways to respond to something frightening. Patients write down their irrational beliefs and thoughts and figure out more helpful responses, based on a rational interpretation of events devised with the therapist. Regardless of whether treatment is with behavior modification or psychotherapy, it should continue for at least 6 months. Eventually, most patients will come to believe that their symptoms are due not to personal weakness but as a reaction to severe stress. Especially at the onset of treatment, most patients need medication. Antidepressants are a good first choice because they attack most of the anxiety symptoms as well as the depression that so often accompanies this disorder. Although any of the other SSRIs would probably have worked, Aretta started on sertraline (Zoloft). Once she got to 100 mg/day, her mood symptoms and eventually her insomnia improved. Some studies suggest that the monoamine oxidase inhibitors work especially well for the insomnia and recurring thoughts, dreams, and memories. Recent studies have shown that the alpha-1 adrenergic blocker prazosin (Minipress) can be helpful for someone who is especially troubled by flashbacks, nightmares, or symptoms of hyperarousal (poor concentration, easy startling). Mood stabilizers such as lamotrigine have been effective against PTSD symptoms in civilian and military patients. Whichever drug is chosen, it will probably be needed for at least a year. Symptoms of PTSD that sometimes develop in ICU patients have recently been prevented by getting them out of bed and walking, to the extent permitted by their medical complications.

Course of illness
Even without treatment, about half of PTSD patients recover within a few months, and many others experience relatively mild symptoms. Only about 10% of those who develop PTSD remain ill for many years. Of these, some have symptoms that wax and wane, and only a few seem to become worse and worse. However, even a small percentage of a huge base still yields a large number (consider just the millions of people who have seen combat in the past 60 years). A favorable outcome is likely in those who do not experience subsequent episodes of trauma, who have a good social support system, who dont have other mental disorders, including substance misuse, and who manage either to avoid or discard maladaptive coping devices such as the use of denial and isolation. Of course, seeking out and adhering to treatment is an important step in promoting recovery.

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Editorial: Speaking of Avoidance

A terrific approach to any traumatic event would be to prevent PTSD from developing in the first place. Thats the intent of debriefing, in which the incident is reviewed with the victim, immediately and in detail, using deep probes to elicit the emotions and thoughts experienced. By providing information about common emotional reactions to trauma and stressing the importance of talking about the incident, this approach is supposed to avoid the development of symptoms. However, careful scientific studies have proven not only that that the one-shot debriefing process doesnt prevent PTSD, it actually makes some people worse. Antianxiety drugs, taken just after a severe automobile accident or other trauma, dont seem to prevent PTSD, either. On the brighter side, some evidence suggests that starting CBT soon after the trauma may help prevent the onset of PTSD. Another caution concerns the issue of compensation. In our litigious society, whenever bad things happen, someone must pay, especially if that someone has deep pockets. Such litigation is likely to be hard-fought and prolonged, and the outcome may depend on the apparent degree of damage. Someone who must demonstrate continuing symptoms to prevail in court risks prolonging the disability. Balancing the need for recovery with the desire for compensation can pose a real dilemma. Every physician should be prepared for a frank discussion with patients about the health benefits of returning as soon as possible to normal daily life.

Acute Stress Disorder

Anyone whos been paying really close attention will have noticed a hole in the PTSD criteria: They say nothing about people whose trauma occurred within the previous month. Thats where the relatively new diagnosis of acute stress disorder comes in. What else should we note about such patients? For one, they are defined similarly to PTSD; in the table below are the essential differences. Full abbreviated criteria (I know, its an oxymoron) are given in Table 7b at the end of the chapter.
Trauma Dissociative symptoms Reliving the event Avoidance Increased arousal Duration Distress or impairment R/o substance, medical cause Posttraumatic Stress Disorder Actual, threat fear, helplessness, or horror None required (may be part of reliving) 1+ required 3+ required 2+ required More than 1 month Yes Not required (!) Acute Stress Disorder Same 3+, during/after trauma 1+ required 1+ required 1+ required 228 days Yes Yes

The most important factor that determines how a person will react to trauma is the nature, especially the degree of that trauma. A particularly horrendous experience can cause acute symptoms, even in someone with no risk factors for a stress disorder (page 107). Some ASD patients go on to develop PTSD; others gradually improve on their own. The editorial box makes it clear that debriefing isnt especially effective, but there are steps that can be taken to improve the outcome for people who have been acutely, recently traumatized. A series of recent articles from Australia demonstrate that prolonged (imaging followed by in vivo) exposure therapy cut in half (33% versus 77%) the likelihood of longer-term symptoms among survivors of civilian automobile accidents or nonsexual assault. Exposure was more effective

Anxiety and Panic than cognitive restructuring, which still produced enough improvement that it should be considered for those who are unable to withstand the rigors of prolonged confrontation. At 6month follow-up, patients maintained their improvements.

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ObsessiveCompulsive Disorder
We sometimes speak casually of being obsessed with a thought or idea; we may describe someones behavior as being compulsive. Then, were talking about simple exaggerations of normal thinking and behaviorwhat we mean is that the person pursues an idea excessively or insists that something be done a particular way. In contrast, clinical obsessions are unwanted mental events that shove their way into consciousness, interrupting the normal course of thought; compulsions are mental acts or repetitive behavior that someone feels the powerful urge to perform, usually to decrease the anxiety caused by an obsession. Judy and Peter Digby went for marriage counseling (divorce counseling, Peter called it) because they fought constantly about their 17-year-old daughter. On one point they agreed: Paulettes problem was tearing the family apart. It started a year earlier when one of her jobs was taking out the garbage. She wore gloves to do this because she had seen a TV show about bacteria. Putting on rubber gloves whenever she grasped the lid gradually developed into a complicated routine for removing the gloves without touching the outsides of them with her fingers. She also spent a lot of time in the bathroom. Whenever her mother asked what she was doing, shed say nothing, but once she forgot to lock the door. Judy peeked in and saw her scrubbing her hands, even though she had just showered. That evening, Judy confronted her about her 10 visits to the bathroom that day. Paulette cried, Its stupid and I hate it, I just cant help it. I just cant stop thinking about germs, and I always feel so yucky. That was several months earlier. Now she washed half an hour at a time, at least a dozen times a day. Otherwise, she wore three pairs of gloves. When she slept, she wore only one (I might get up and touch something). She even had special gloves for washing the other gloves. Every couple of days, Paulette cleaned the kitchen, starting with the sink and stove, working her way through the cupboards, and finishing up under the sink. For the last several months her mother had helped her, scouring the already sparkling floor on her hands and knees. (She seemed so frantic, Judy explained, I had to do something.) From her volunteer job at the hospital, Judy had brought home scrub booties, which the whole family had to wear indoors. Paulette had also taped all the doorknobs so that none of the latches in the house workedshe could push or pull the doors open with her wrist. At about that time, two events coincided: her sister Candy, fed up with the home climate, moved out to live with her boyfriend; and Peter stopped cooperating with his wifes need to protect their daughter by joining the extreme behavior. Judy only redoubled her efforts, which made him even angrier at his daughter. Shes dragged the whole family down, he grumbled. She makes a production out of what normal people take for granted.

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Symptoms and diagnosis of OCD

Paulette couldnt control her thoughts about contamination, and she couldnt resist performing the rituals that momentarily reduced her anxiety about germs. The obsessions and compulsions that absorbed her life, divided her parents, and drove away her sister constitute obsessivecompulsive disorder (OCD). Paulettes fixation on cleanliness is a common obsession. Other obsessions involve thoughts (distressing ideas about sex and numbers that are believed to be unlucky), pictures or images of dreaded actions (such as disrobing in public), fears (perhaps of diseases like AIDS or hepatitis), mental acrobatics (for example, visually dividing a line exactly in two), and impulses (feeling compelled to scream during religious services). These mental events are often violent, disgusting, sacrilegious, sexual, or senseless. Paulette responded to her obsessions by cleaning compulsively; others count or check things, such as locks, or gas and electric appliances. Still others have no obsessions at all, just compulsions that they must perform according to set rules. Joseph could only get into bed at night by following an agonizing procedurestep in and out of his slippers three times (later, three times three, then three times three times three); smooth out his bedspread, turn it down to a 45-degree angle three times, put his pajamas on bottoms first, then tops, remove them, and repeat three times. If he was interrupted or began to doubt whether he had followed all the prescribed steps, he had to start all over again. The obsessional ideas can generate enormous anxiety, whereas attempts to resist compulsions can lead to tension that is ultimately relieved only by giving in to them. A few people have obsessional slowness, in which it takes hours to complete a simple household chore. Others have mental compulsions (such as ritualized praying) that are not externally apparent. A very few have obsessions without compulsions. Paulettes condition developed so gradually that it took months for her family to seek professional help. At its onset, the problem may seem innocuous, and relatives like Paulettes mother may try to ease the persons fears by assisting with the rituals. However, the more the person performs compulsive rituals, the worse the OCD becomes. OCD sufferers often devote much time to what most of us might view as the infrastructure of our lives. They usually recognize how peculiar their obsessive thoughts and compulsive rituals must seem, and feel embarrassed. Thats partly why OCD was once thought to be rareshame and the fear that they are going crazy make people hide their guilty secrets even from best friends and physicians. Differential diagnosis Anxiety due to substance use Anxiety due to a medical condition Major depression Somatoform disorders (Hypochondriasis, Body dysmorphic disorder) Substance misuse GAD Panic disorder Social or specific phobia

Anxiety and Panic Impulse control disorders (hair-pulling, pathological gambling) Psychotic disorders Adjustment disorder Everyday superstitions and checking behavior Obsessive-compulsive personality disorder*

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Sidebar: Obsessed with Imperfection

Stunning and statuesque, at age 23 Tamara was consulting her third plastic surgeon about her nose. The first two hadnt thought they could improve on natures gifts, but Tamara was unconvinced. Im ugly and misshapen, she insisted as she scrutinized herself in her hand mirror. She had lost several boyfriends over her preoccupation with her nose; she had lately begun wearing her long hair draped across half her face. Tamara had body dysmorphic disorder (BDD), a condition first described over 100 years ago. Even mental health professionals often dont know a lot about it, though as many as 1 or 2% of adults, and even some children, may be affected. These men and women (who are about equally represented) are haunted by their appearance. Where others see beauty, or perhaps the slightest hint of a flaw, they perceive only disaster. Theirs is an obsession with the impression of imperfection. Most often, they worry about the appearance of skin, hair, or nose, but hardly any body part is immuneankles, arms, even the pubic bone of one teenager. People with BDD may spend much of the day brooding over their imagined deformities. Almost all have impaired social lives, and over 80% have trouble on the job or at school. Half are hospitalized at some time; nearly a third become housebound. If they do go out, they may try, like Tamara, to conceal their features with clothing or bandages. Most check mirrors compulsively and compare themselves mentally to those they meet. To smooth away the tiny bumps and blemishes only they can see, they may pick or scrape away at their skin until real pitting and scarring develop. Most have had major depression, and nearly one-fourth have made a suicide attempt; a few succeed. In the effort to repair their fancied deficits, many patients with BDD request surgery. Too often, they are obliged and, usually, they are dissatisfied with the outcome. Even those who think they have been improved may just shift critical attention to another body part. No one knows what causes BDD, though it probably involves a problem with serotonin neurotransmission. Although repeated double-blind studies have not yet been done, it appears so far that drugs like fluvoxamine (Luvox), given in high enough doses and for long enough (typically, 1216 weeks), will help around two-thirds of patients with BDD. The TCA clomipramine (Anafranil) can also help, and for patients who need even more assistance, the combination of fluvoxamine plus clomipramine, cautiously administered, may work well. Some clinicians find that buspirone (60-90 mg/day) augments the antidepressant effect. Exposure and response prevention (ERP) can help reduce the anxiety and unwanted behaviors. It encourages patients to stop clinging to the behaviors they have used to escape from their fears. Tamara would be persuaded to throw away her cover-ups and discard her magnifying mirrors. Low-wattage light bulbs in the bathroom may help shift focus from their appearance.
Note the differences between OCD and OCPD: patients with the former have actual obsessions and/or compulsions. Patients with the latter are concerned with issues of control, orderliness and perfectionism. A given patient could have both conditions, in which case both diagnoses would be made.
*

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However, patients with severe BDD will probably also need long-term thought repair through CBT: identifying automatic and unrealistic thoughts and core beliefs, challenging them, and replacing them with more useful thinking. For example, Tamara learned to tell herself that her thoughts about her nose were just part of her BDD. A complex illness that continues to perplex patients and professionals alike, BDD falls into what some call the OCD spectrum of disorders, a group that also includes Tourettes disorder, anorexia and bulimia nervosa, and kleptomania, each of which features obsessional thinking and ritualized behaviors. Each of these disorders is included in a DSM-IV section different from OCD and the other anxiety disorders; it remains to be demonstrated to what extent they might be related.

Epidemiology, etiology, and comorbidity

We now know that OCD is actually fairly common, at some time affecting about one in 50 people. It is somewhat more frequent among women than men, though boys tend to outnumber girls (it begins earlier in boys). In both sexes, it usually begins in the teens or early 20s, though it can affect children of 10 or even younger. OCD has strong biological roots. Although the genetics arent thoroughly worked out, several studies have found that OCD in a relative increases a persons risk for the disease fivefold. There is also a familial link to Tourettes disorder, the uncontrollable and disconcerting tendency to have motor tics and blurt out obscenities. Positron emission tomography has found abnormal metabolism at sites deep within the brains of people who are having obsessions; these abnormalities resolve with effective treatment. In recent years, childhood OCD has developed apparently as an immune reaction to streptococcal infections. Whatever the initial starting point, biologists have uncovered considerable evidence implicating the neurotransmitter serotonin; SSRI drugs such as fluvoxamine and the TCA clomipramine are effective in treating OCD. OCD patients are likely to have other anxiety disorders (phobias, panic, GAD), no surprise. In addition, they may have major depression, eating disorders, OCPD, and tics and Tourettes disorder.

Treating OCD
Two basic approaches, drugs and psychotherapy, can effectively address OCD. Patients with complicated, longstanding, or moderate to severe OCD should probably use both. In an effort to jump-start the recovery effort and ensure success, Paulettes physician began with the SSRI fluvoxamine at 50 mg/day and increased it by 50 mg every 4 or 5 days. At 200 mg/day, she felt less stressed and was referred to a therapist for treatment with (ERP). Paulette was told that she would improve faster if she intentionally contaminated herself by touching germ-laden objects; she reluctantly surrendered her gloves and spent an hour each day rubbing her hands in a bucket of dirt (exposure). The response prevention part: she was allowed to wash her hands only four times a day. The anxiety was really terrible at first, she later admitted. Mom had to sit with me for the first hour or so each day. After a few days, though, I lightened up. Typically, high doses (and sometimes, a long duration of treatment) are needed for the SSRIs to be effective. Fluvoxamine has been specifically approved by the FDA for OCD, though other

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SSRIs have also proven effective. Trials of different drugs may be needed to find the one that works best. The tricyclic antidepressant clomipramine, starting at 25 mg/day and increasing to an average of 200250/day, is effective but is beset with side effects and has a slow response time. Some patients need augmentation of an SSRI with clomipramine or with a low-dose atypical antipsychotic agent such as olanzapine or risperidone. ERP works best for patients who are highly motivated and have both obsessions and compulsions. Had Paulette been unable to tolerate the anxiety ERP sometimes generates, CBT would have been an alternative, though perhaps less effective, intervention. If she had had only obsessions, she could have been offered the thought stopping method (where the patient, upon experiencing obsessional thinking, visualizes the therapist banging a fist on the table and shouting Stop!). There is no evidence that dynamic psychotherapy is of much use; this lack of evidence parallels most clinicians abandonment, in recent years, of inner conflicts as a cause of OCD. Include families in the overall treatment plan. Relatives need education so that they can stop casting blame (on themselves and the patient) for behavior neither can control. It is also vital that those who live with an OCD patient learn to stop accommodating the compulsions. Paulettes family had to stop using gloves and decontaminating the housethese behaviors reduced Paulettes anxieties short-term but ultimately worsened the problem. Although it only rarely comes to this, neurosurgery remains a possibility for those rare patients who are incapacitated by OCD and who respond to nothing else. Currently, thermal capsulotomy is the procedure of choice. About a third of patients who have such surgery function better.

Course of illness
Severe OCD is hard to treat. Although medication or psychotherapy alone may help those with milder symptoms, those with more severe symptoms and their families should brace themselves for a long campaign. OCD patients generally have more trouble achieving a satisfactory response if theyve been hospitalized or more or less continuously ill; if they have washing rituals; if they also have a personality disorder. However, even for those who continue to have some symptoms, with vigorous treatment the overall outlook is far brighter than it was even a couple of decades ago.

Anxiety Due to Physical Illnesses or Substance Use

You wont find physical illnesses and substance use as causes of most of the named disorders weve covered in this chapter, but that doesnt mean we can relax our vigil for medical causes of anxiety. For example, though repetitive behaviors occur in Tourettes disorder and in temporal lobe epilepsy, they dont spell out the criteria necessary to diagnose OCD. However, for the unwary, there is still plenty of opportunity to miss readily correctible etiologies of nonspecific anxiety symptoms. In the Table 8 listing of a variety of mental symptoms associated with 60 medical disorders, youll find that many of them include anxiety.

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Review
Isaac had his first attack when he was 16. It was during an algebra test that his heart started pounding so hard he couldnt concentrate on the paper in front of him. He asked to be excused and stumbled out of the classroom. A few moments later, the teacher found him sitting on the bathroom floor, gasping for breath and clutching his chest. The next day, his family doctor pronounced him physically sound, but in the 20 years since, hes had episodic attacks of feeling acutely frightened and disoriented. Beginning abruptly and without warning, Isaacs attacks rapidly swell to a terrifying climax. His heart pumps so fast that he cant even count the beats and he feels like all the breath has been sucked out of him. Sometimes a pain begins on the left side of his chest and surges like a tidal wave, spilling into his abdomen and pelvis. At first his vision blurs, then narrows, until he loses his peripheral vision. Isaacs attacks have occurred in a variety of circumstancesat the theater, on his job as a city planner, while driving to visit his mother, even once as he and his wife were making love. He may go for several months without much trouble at all, then experience attacks daily for weeks on end. Nearly every time it happens he thinks, Im about to draw my last breath. He can sometimes abort his attacks by breathing into a small paper bag, but he feels desperate to find something that will get rid of them permanently. 1. What symptoms of panic attack did Isaac have? Which did he lack? [p 91] 2. Outline the steps you would recommend for treatment of Isaacs symptoms. [ p 92] 3. Suppose Isaacs symptoms had begun after his involvement in a fatal automobile crash. What three sets of symptoms would you especially be looking for to rule in/out PTSD? [p 106] 4. What named phobia does Isaac suffer from, and what are the other two classes of phobia we currently diagnose? [p 92; also 96, and 107] 5. How do the treatments recommended for these three classes of phobia differ? [p 94, 98, and 101 6. What diagnoses would you put at the absolute top of your differential diagnosis for Isaac? [p 114] 7. Suppose Isaac had obsessive thoughts concerning recurring panic attacks; what evidence would allow you to decide whether he also suffered from OCD? [p 117] 8. Of course, Isaac worries about his panic attacks. What circumstance(s) would permit you to diagnose GAD? [p 103]

Substance Misuse Table 7a. Simplified Criteria for DSM-IV Anxiety Disorders Disorder Symptoms
Panic disorder w/ Agoraphobia: Recurrent, unexpected panic attacks* and Agoraphobia Panic disorder, w/o Agoraphobia: Recurrent, unexpected panic attacks* Agoraphobia w/o history of panic disorder Specific phobia: A strong, persistent, fear that is excessive or unreasonable is set off by an object or situation that is present or anticipated For a month or longer, 1+ of: Concern about more attacks Worry about meaning of attacks, consequences Material change in behavior (eg, doing something to avoid or combat attacks

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Exclusions/Other
Not caused by substance use, GMC

Does not have agoraphobia Not caused by substance use, GMC

Meets criteria for agoraphobia

Social phobia: A strong, repeated fear of showing anxiety sx or embarrassment while watched by others

Phobic stimulus almost always causes anxiety (may be panic attack) Patient realizes fear is unreasonable or excessive Patient avoids stimulus or endures w/ severe distress Under 18, must have symptoms 6 months or more Marked distress, or interferes with patients usual routines or personal, social, work functioning

Generalized anxiety disorder

Clinical distress or impaired work, social, personal functioning No other mental disorder better explains symptoms Not solely during delirium Prominent anxiety, panic, obsessions, compulsions Clinical distress or impaired work, social, History/physical exam/laboratory evidence either: personal functioning Substance-related anxiety Symptoms developed within 1 month of intoxication No other mental disorder better explains disorder or withdrawal, or symptoms Medication use caused symptoms Not solely during delirium *Criteria for panic attack: sudden onset of episode that peaks within 10 minutes; 4 or more of: Chest pain or other chest discomfort; Chills or hot flashes; Choking sensation; Derealization; Dizzy, lightheaded, or faint; Fear of dying; Fears loss of control or insanity; Heart pounds, races, skips beats; Nausea, other abdominal discomfort; Numbness or tingling; Sweating; Shortness of breath or smothering sensation; Tremor Criteria for agoraphobia: (1) One or both of a) Anxiety about being where escape is difficult or embarrassing, b) if attack occurs, help might not be available. (2) The patient a) Avoids these situations/places, or b) Endures them, but with distress, or c) Requires a companion. (3) No other mental disorder better explains the symptoms. Anxiety disorder due to general medical condition

More than half the days for 6+ months, excessive anxiety and worry about several events or activities 3+ of: Feeling restless, edgy, keyed up Tiring easily Trouble concentrating Irritability Increased muscle tension Trouble sleeping Prominent anxiety, panic, obsessions, compulsions History, physical exam or laboratory evidence suggest a GMC has caused symptoms.

Never has met panic disorder criteria Not caused by substance use, GMC Not better explained by another anxiety or mental disorder Specify type: Situational (eg, air travel) Natural environment (eg, heights, thunderstorms) Bloodinjectioninjury Animal Other Not better explained by another anxiety or mental disorder Not caused by substance use, GMC Specify whether Generalized (patient fears most social situations) Not caused by substance use, GMC Another Axis I disorder doesnt provide the focus of the anxiety and worry Doesnt occur only during mood, psychotic disorder or PTSD or pervasive developmental disorder

Substance Misuse Table 7b. Simplified Criteria for DSM-IV Anxiety Disorders (cont.) Disorder Symptoms
Obsessivecompulsive disorder Obsessions, compulsions,** or both. At some time during illness, patient recognizes that these are unreasonable or excessive. Symptoms cause 1+ of: severe distress, take up time (>1 hr/day), or interfere with usual routine or personal, social, work functioning

117 Exclusions/Other
If patient has another Axis I disorder, content of obsessions/compulsions not limited to it Not caused by substance use, GMC Symptoms last > month Score as: Acute (symptoms last <3 months) Chronic (symptoms last more than 3 months) With delayed onset (symptoms begin 6+ months after the stressor)

Posttraumatic stress disorder

Traumatic event experienced or witnessed by patient (1) involves actual or threatened death or serious physical injury to patient or others and (2) patient feels intense fear, horror, or helplessness Patient repeatedly relives event in 1+ of: (1) Intrusive, distressing recollections; (2) Repeated, distressing dreams; (3) Feels as though events are reoccurring (e.g., flashbacks); (4) Marked mental distress reacting to cues that symbolize some part of the trauma; (5) Physiological reactions to these cues (e.g., tachycardia, increased BP) Patient repeatedly avoids stimuli and has numbing, shown by 3+ of: (1) Tries to avoid feelings, thoughts, conversations; (2) Tries to avoid activities, people, places that recall the trauma; (3) Amnesia for an important feature of the trauma; (4) Has markedly decreased interest or participation in important activities; (5) Feels detached or isolated from others; (6) Restricted ability to love or feel other strong emotions; (7) Feels life will be brief or unfulfilled 2+ of these new hyperarousal symptoms: (1) Insomnia; (2) Angry outbursts or irritability; (3) Poor concentration; (4) Excess vigilance; (5) increased startle response Marked distress, or interferes with patients usual routines or personal, social, work functioning Acute Stress Traumatic event experienced or witnessed by patient (1) involves actual or Symptoms begin within 4 Disorder threatened death or serious physical injury to patient or others and (2) patient wks of trauma feels intense fear, horror, or helplessness Duration is 229 days During or just after the event, patient has 3+ symptoms of dissociation: (1) Not caused by substance use, Feels detached, numb, or emotionally unresponsive; (2) decreased awareness GMC of surroundings, as in a daze; (3) Derealization; (4) Depersonalization; (5) Not just a worsening of Amnesia for important aspects of the event another disorder Patient repeatedly relives event in 1+ of: (1) Recollections (dreams, flashbacks, Not a brief psychotic images, thoughts); (2) Sense of reliving the event; (3) Mental distress as disorder reaction to reminders of the trauma Patient strongly avoids activities, conversations, feelings, people places, thoughts that are reminders of the trauma Marked symptoms of anxiety or hyperarousal, eg excessive vigilance, insomnia, irritability, poor concentration, restlessness, increased startle response 1+ of: (1) Symptoms cause patient marked distress; (2) Interfere with patients usual routines or personal, social, work functioning; (3) Block patient from doing something important, such as getting legal or medical help or tell others about the experience Criteria for obsessions. All are required: (1) Recurring, persistent thoughts, impulses, or images inappropriately intrude into awareness and cause marked distress or anxiety; (2) These are not just extreme worries about ordinary problems; (3) Patient tries to disregard, suppress, or neutralize them; and (4) is aware they are the product of the patients own mind. **Criteria for compulsions. All are required: (1) The need to repeat physical or mental behaviors (e.g., counting, handwashing); (2) Behaviors occur in response to an obsession or in accordance with strictly applied rules; (3) Behaviors aim to reduce distress or prevent something that is dreaded; (4) Behaviors are either not realistically related to the events they are supposed to counteract, or are excessive for that purpose.

Substance Misuse Table 8. Mental/emotional symptoms associated with selected physical illnesses
Emotional/behavioral Symptoms Hallucination s Delusions Suicide Ideas Labile mood Obses/comp Withdrawal Judgment Depression Catatonia Cognitive symptoms Disorientation Memory Slow Thought Inattention Dementia Delirium

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Mania

Adrenal insufficiency AIDS Altitude sickness Amyotrophic lateral sclerosis Antidiuretic excess Brain abscess Brain tumor Cancer Cardiac arrhythmia Cerebrovascular disease Chronic obstructive lung disease Congestive heart failure Cryptococcosis Cushings Deafness Diabetes mellitus Epilepsy Fibromyalgia Head trauma Herpes encephalitis Homocystinuria Huntingtons Hyperparathyroidism Hypertension Hyperthyroidism Hypoparathyroidism Hypothyroidism Kidney failure Klinefelters Liver failure Lyme disease Menieres Menopause Migraine Mitral valve prolapse Multiple sclerosis Myasthenia gravis Neurocutaneous diseases Normal pressure hydrocephalus Parkinsons Pellagra Pernicious anemia Pheochromocytoma Pneumonia Porphyria Postoperative states Premenstrual syndrome Prion disease Progressive supranuclear palsy Protein energy malnutrition Pulmonary thromboembolism Rheumatoid arthritis Sickle cell disease Sleep apnea Syphilis Systemic infection Systemic lupus erythematosus Thiamine deficiency Wilson's

x x x

x x x

x x x

x x x x

x x x x

x x

PTSD

Panic

x x x

x x x x

x x x x

x x

x x x x x x x x

x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x

x x x x x x x x x x x x x x x x x x x x x x x x x

x x x x x x

x x x x x x x x x x x x x x x x x x

x x x x x x x x

x x x

x x x x

x x x

x x x

x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x

x x x

x x

x x

x x

x x x x x x

x x x x

x x x x

x x

x x x x

x x x x x x x

x x x

x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x

x x x

Adapted from Morrison J: Diagnosis Made Easier. New York, Guilford, 2007.

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Further Learning
I dont have nearly enough recommendations for works that will guide you inside the mind of people who have anxiety disorders. Id appreciate hearing from anyone who has run across such material. For GAD, there is Fear Strikes Out, the story of Jim Pearsal, who played baseball for the Boston Red Sox back in the mid-Twentieth Century. Please email me with any thoughts you may have about other works that are especially good at portraying people with anxiety disorders. Ruth Rendell: in Live Flesh, her main character Victor has a morbid fear of turtles (chelonaphobia), so severe that he cannot bear even to hear the word pronounced. Panic came over him like a kind of electric suit Victor has and aunt with agoraphobia, and author mentions a kind of systematic desensitization in passing. The British mystery writer Ruth Rendell (and her nom de plume *) have turned out dozens of titles in the past 40 years. A number of them feature characters with rather well-drawn mental disorders, especially anxiety disorders. Here is are a few of them: Victor in Live Flesh is an almost inadvertent killer who has a morbid fear of turtles. A minor character in The Bridesmaid is Cheryl, sister of the protagonist, who suffers from well-described pathological gambling [chapter 19]. She has completely lost control of her gambling, doesnt see it as a problem (an interest or hobby), borrows and steals to support her addiction. Demon in My View features Arthur, a psychopath who strangles women. In Grasshopper, the heroine, Clodagh Brown, has incapacitating claustrophobia, yet she enjoys climbing on roofs of building. Winston in 1984: a fear of white rats [check this out].

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CHAPTER X

Substance Misuse
11,346 Despite huge investments of resources into understanding causes and devising effective treatments, our society continues to struggle with substance abuse. Headlines in early 2001 cited substance abuse as the number-one health problem in the United States. Although some people still consider abusers of alcohol and other substances to suffer from nothing more that moral laxity, careful study has proven substance misuse* to be no different from any other medical disease. Like many other conditions, substance abuse disorders run in families, have distinct symptoms, psychopathology, and courses, respond predictably to certain treatments and, if not treated, have well-defined, predictable outcomes. These characteristics have led experts to refer to substance dependence as a chronic illness that should be regarded like any other chronic medical disease as regards insurance, evaluation, and treatment. Some people in the early stages of substance misuse stop instantaneously, or with a nudge. If they keep using and dont seek help, many medical complications and emotional and behavioral sequels are possible: disorders of mood, anxiety, sleep, and sex, as well as psychosis, dementia, and delirium. Clinicians without much specialized mental health training often provide services for patients with substance use problems, so it is imperative that general physicians have a strong working knowledge of how different drugs affect emotions, cognition, and behavior, and cover many aspects of treatment, both in general and for specific addictions. The language we use to describe and define substance use disorders rest on four pillars: intoxication and withdrawal, abuse and dependence. Well use the slightly artificial device of the composite Monaghan family to illustrate these concepts. Del Monaghan, a 45-year-old salesman, had tried marijuana a few times in college. Early one Sunday morning, intoxicated on vodka, he had to stop every block or so just to bring the street ahead into focus sufficient to continue the drive home. The following day, as his headache subsided, guilt and fear made him resolve never again to put himself in that position. Even today, when he attends a ball game hell drink a beer or two, but never three, and he has exactly two cups of coffee each morning. Del worries about his daughter Eva, 21. In her final college year, Eva got two tickets for driving while intoxicated and had several times been too hung-over to attend class. She and her mother spent Christmas vacation fighting about her drinking, but she refused to seek treatment. She even stayed sober for 2 weeks, just to prove that she didnt have to have it. Remembering his own youthful misadventures, Del couldnt bring himself to confront Eva about her behavior.
*

As well see later, the term abuse has a special and specific diagnostic meaning. It is to avoid confusion that, throughout this book, Ive used the term substance misuse for the generic concept of someone who uses too much of a substance and therefore has problems. Many writers plow right ahead with substance abuse, so what if its confusing? Ive opted for clarity.

Substance Misuse Dels concern is fed by memories of his own father, Stanley, a self-made man who never finished high school but had used his experience as a produce buyer to become a grocery importer. By the time he was 40, Stanley was proud and wealthy, and often drank a fifth of bourbon in a day without so much as slurring his words. Within a few years, he had neglected his business and was drinking his way through the family savings. Threatened with divorce, Stanley consulted physicians and joined AA, all to no avail. When he entered a hospital for the cure, the sudden cessation of drinking precipitated such severe shakiness and nausea that he checked out immediately and returned to the bottle. Months later, he had put his head on Dels shoulder and cried, Im a hopeless alcoholic, Im nothing without a drink! The following winter, he was found frozen to death in an alleyway behind the liquor store.

121

DEPENDENCE AND ABUSE

Eventually, we all overuse something, even if its only caffeine. (Although DSM-IV lists several caffeine-related disorders, no one proposes limiting traffic in coffee.) According to the National Household Survey on Drug Abuse, in 1999 about 40 million Americans age 12 or over reported using an illicit drug at least once, and 7 million had used one or more within the last 30 days. Just using a drug, even an illegal one, doesnt spell a diagnosable substance use disorder. For that to happen, the usage must create significant problems such as with health, finances, family or friends, and the law. Once we spoke of addiction, a term many experts now reject because it is imprecisewe use it for people who like to eat chocolates or read mysteries. Dependence is what we now call heavy, maladaptive reliance on any substance. It is the critical concept for differentiating heavy and severe substance misuse from other forms of abuse and, indeed, from casual and social use. To qualify for dependence of any substance, a patient must experience three of the following seven DSM physiological, cognitive, and behavioral criteria within a 12-month period. Tolerance. Either of: a) the patient markedly increases intake to gain the same effect or, b) continued use of the same amount yields less effect. Withdrawal. Either of : a) the patient experiences withdrawal effects typical for the substance or, b) uses the substanceor a related oneto mitigate or avoid withdrawal symptoms. The amount or duration of use is frequently more than intended. The patient repeatedly tries without success to control or reduce the substance use. The patient spends much time obtaining, using, or recovering from the effects of the substance. Because of substance use, the patient reduces or abandons important work, social, or leisure activities. The patient continues to use the substance, despite the knowledge that it has probably caused ongoing physical or psychological problems.

Stanley easily qualifies as a dependent drinker. His huge intake of alcohol (a quart a day) strongly suggests tolerance to the intoxicating effects of alcohol. The shakiness he experienced

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when in the hospital is typical of withdrawal (had he remained off alcohol a few days longer, he might well have experienced other withdrawal effects such as delirium tremens). Though he tried repeatedly to quit, he neglected his work and his family, spent much of his time drinking, and he continued to drink despite knowing that it was having deleterious effects on his health. In general, the more problems a person has from substance use, the more severe the dependence. Of all the patients I have known, Stanley Monaghan truly ranks among the most severely affected. The severity of dependence varies with the individual, the length of use, and the substance itself. People dependent on heroin tend to have most of these symptoms, and those dependent on marijuana tend to have fewer; the severity of cocaine or alcohol dependence can be all over the map. The vast majority of these people are neither criminals nor homeless derelicts. They have jobs, look normal, have families who care about them, and in most other ways are responsible citizens. Note that Stanley was physiologically dependenthe had experienced both tolerance and withdrawal (only one is needed to qualify). Drinking large amounts of alcohol without appearing drunk indicated that Stanley had tolerance: he needed increasing doses to produce the same intoxicating effect. Each substance has its own characteristic withdrawal symptoms (Table 25.1), including Stanleys shakiness and nausea. However, you dont have to have physiological symptoms to be dependent. Physiological dependence is especially typical of alcohol and heroin use. The criteria for dependence, therefore, rely on issues of physiological change and loss of control. The exact same criteria are used to define dependence for any of 10 possible substances (see Table 1). Polysubstance dependence Oh yeah, there is one other issue you could encounter in the welter of our nomenclature. The formal (DSM-IV) definition of polysubstance dependence is something more than just the use of more than one substance. Technically, it means that the person uses at least 3 substances but doesnt qualify for dependence on any one of them but if the criteria you amass for all 3 are put together, it would equal dependence. For example: During the past year Marcias only symptoms of dependence are these: she often drinks more alcohol than she intends, keeps using cocaine on the weekends despite her doctors warning that its causing her severe mood swings, and she has tried Nicorette gum, a nicotine patch, and group therapytwiceto try to kick her cigarette habit. Marcia doesnt have enough criteria to say that she is dependent on any one substance, but in aggregate, she has 3, so we say she is polysubstance dependent. Substance abuse The foregoing definitions set off substance dependence from another form of misuse, (confusingly) called substance abuse. Whereas these latter patients do have problems resulting from their excessive suse, they lack the loss of control that defines physiological dependencein short, they arent as sick. Rather, the criteria for substance abuse involve legal and social issues: Abuse causes clinically important distress or impairment as shown in a 12-month period by at least one of the following: Repeated use cause the patient to fail to carry out major obligations at work, school, or home.

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The patient repeatedly uses the substance even when it is physically dangerous to do so (such as driving or operating heavy machinery). There are repeated legal problems from the substance use. The patient continues to use the substance, even knowing that it has caused or worsened social or interpersonal problems.

If the patient has ever fulfilled criteria for dependence on that substance, abuse cannot be diagnosed for that substance (though it could be diagnosed for another substance). Also, there is no such thing as polysubstance abuse. Although you wouldnt consider Eva alcohol dependent (she quit for 2 weeks and she lacked other symptoms that suggest loss of control or physiological changes), drinking had led to fights at home and missed classes, and shed had a couple of citations for driving while intoxicated. By the above criteria, Eva is an abusive drinker. But just what does it mean to label someone a substance abuser? To be valid, the diagnoses we use must enable us to make predictions. Whereas there is evidence that some abusers progress to become dependent, most do not; factor analysis reveals equivocal support for validity of alcohol abuse; whereas support for dependence is robust. Further, contrary to expectations, these criteria sets dont appear to be hierarchical: criteria for abuse tend to be sprinkled among dependent patients, not clustered tightly together, and many dependent patients dont also have abuse criteria. Furthermore, there are still other patients who have been problematic users without qualifying for either substance dependence or abuseso-called diagnostic orphans who fall between, or among, diagnostic stools. All of this suggests that the present nomenclature may not survive the move to DSM-V, now scheduled for 2012. Stay tuned.

Etiology and development of substance misuse

In an earlier millennium, one of my professors liked to say that the cause of alcoholism was alcohol. Its true, to a point: if you never take a drink, you cannot become alcoholic. But if the mere presence of a substance could produce a substance abuse problem, wed be awash in chemically dependent people. We might start by asking, whats the attraction? One big factor, especially for the young and impressionable, is the siren song of peer influenceglamour and social acceptance are especially powerful promoters of common substances such as alcohol, nicotine, and marijuana. Opioids, sedatives, and stimulants may provide relief from boredom, fatigue, or pain; alcohol can brighten a gloomy mood, augment sociability, and reduce sexual inhibitions. Inhalants offer a cheap, readily obtainable resource for reduced inhibitions and giddiness, whereas the hallucinogens promise interesting hallucinations and a refuge from reality. The attractions for various substances are given in Table 1. Later on, of course, the mere prevention of withdrawal symptoms may prove attractive enough to ensure continuing use. Besides the approval of peers, a number of issues in peoples lives correlate with drug use: a dysfunctional family, problems in school, a tendency toward impulsive behavior, cultural notions of tradition, even religious sanctions (or proscriptions). But even these factors together cannot explain why some people become heavy users while others, after a trial or two, give it up or continue to use moderately. Many studies combine to suggest a genetic linkage. For example, biological relatives more likely than adoptive to have alcoholism, and around 25% of male first-degree relatives of

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alcoholics are also alcohol dependent. And, as is so often the case, identical twins are more concordant for alcoholism than fraternal. For most drugs overall, the inherited risk for misuse approaches 50% of the variability. (In Asian populations a gene, the ADH2*2 allele, may help protect against the development of alcoholism.) From 10 to 15% of substance users have comorbid schizophrenia, depression, or an anxiety disorder; some of these, especially schizophrenia patients, may be trying to treat their own symptoms by using substances. Learning theorists hold that we develop new behaviors by copying what others do. The tobacco companies attract new victims each year solely because their advertisements link cigarette use with beauty, health, and fun. Some shy people find that drugs and alcohol help them make friends, a powerful reinforcer of further substance use. (On the other hand, deterrents are relatively few: some religions (for Mormons and strict Muslims), physiology (for those oriental people who are intolerant of alcohol), and the law (not very effective in western societies). Whatever the initial attraction, the neurotransmitters dopamine and serotonin may also play a role in producing both the intoxication and withdrawal states from cocaine and alcohol. A dopamine release reward system may help explain how drug dependence develops and is maintained. Most substances of misuse cause an increased in the release of dopamine in the nucleus accumbens and other ventral brain locations. The nucleus accumbens is the site of increased release of dopamine in response to the presence of alcohol, amphetamines, cannabis, cocaine, heroin, and morphine, thus reinforcing the use of these substances. And an expanding literature suggests that alcohol and other drugs may increase endorphins, further enhancing the predilection for substance misuse. In fact, all of the above factors are probably important in causing substance misuse; some have even suggested methods of treatment. It is especially important to discredit the idea that people drink or use drugs just because they lack willpower or have weak characters.

Substance-related illnesses
This short but important section alerts us to the fact that many substance using patients also have other mental disorders. In fact, about half of those seeking treatment for a substance use disorder have another mental disorder, though other studies suggest that in many cases, these other disorders may be mood or anxiety disorders induced by the substance use. On the other side of the coin, many patients with Axis I or II disorders also have a comorbid substance use disorder. In schizophrenia, for example, 40-50% are so affected (exclusive of nicotine, which runs as high as 90%). For mood and anxiety disorders the associations are positive, though not necessarily as striking. Some data suggest that in many instances, substance misuse develops subsequent to, and possibly because of, another Axis I disorder. The use of substances can be primary (driving the mental disorder) or secondary; it is often hard to know which is which. Which comes first chronologically is a help. For example, Stanley Monaghan may have been clinically depressed. The vignette doesnt give nearly enough details, but it would be a reasonable assumption that his depression began long after his heavy drinking was well established. His depression might well have been due to effects of alcohol. The reason we should care: Whether the substance use comes first or second has important consequences for treatment. For example, had we evaluated Stanley for depression, we probably wouldnt have gone straight to the use of antidepressant medications, which might have the unhappy effect of adding the effects of a prescribed chemical on top of ethanol. A rational treatment approach would be first to withdraw him from alcohol, then reassess the need for

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specific treatment for depression. (Alcohol free, any residual depression might respond well to CBT or another form of psychotherapy.) Similar arguments could be made for a variety of disorders, including mood, anxiety, psychotic, sleep, sexual, and cognitive. These are summarized in Table 4, which refers to the appropriate page for complete diagnostic criteria.

Sidebar: Getting Your Patient into Treatment

Studies suggest that the treatment rates for drug dependence are under 40%; for abuse, under 10%. Persuading people to become patients can be difficult, especially if the urge to use is stronger than the desire to stop. (Samuel Taylor Coleridge, who was a heavy user of opium throughout his adult life, wrote of being chained by a darling passion.) There are a lot of factors working against you as you try to steer your patients away from the allure that can destroy them. For some habits such as cigarette smoking, a physicians urging to quit can be determinative. For other substances, the solution may be less readily achieved. Various means of assistance and coercion could play a pivotal voice in a users decision to change. Frank discussion. Here is my first approach, almost every time. It uses evidence from the patients own history as persuasion to enter treatment. Building on the history of, for example, a recent job loss or a ruptured relationship, it would encourage the patient to express emotions, thoughts, and feelings about what might have gone wrong or how it might have been prevented. Any mention of the role of substance misuse would be immediately reinforced (Good insight. Great thinking!) until the patients everyday thinking finally begins to reflect these ideas. Employee assistance. Many corporations and government agencies offer professional help through voluntary programs. Work/school coercion. The threat of job loss or academic expulsion can be a powerful stimulus for change. The military has made especially effective use of this mechanism, as have the professional diversion programs offered physicians as an alternative to loss of license. Spousal leverage. Those we live with and love powerfully shape our behavior. Throughout college, Nathan had habitually used alcohol, cocaine, marijuana, and tobacco. When he was 25 he met Nan; after a prolonged courtship, she agreed to marry himwith the understanding that, if he resumed using drugs, she take any children they might have and leave him. Three years later he slipped and began drinking; after 2 weeks Nan packed up her bags and the baby, and stood at the front door. That was the last time he used anything; 8 years later he is still clean, sober, and smoke-free. Children. When the user is a minor child, a parents legal leverage to command evaluation and treatment is strongassuming the appropriate professionals are available and affordable. Court. Patients who enter treatment in lieu of punishment for crimes or misdemeanors committed while intoxicated do about as well as voluntary patients. Mass persuasion. A critical mass (at least three or four) of relatives and friends, all expressing the sameeven unwelcometruths, can motivate a user to take action. Unhappily, these principles are often easier to state than to apply; for several reasons we hesitate to apply pressure to save the lives of those they care for. Especially if the person is a parent or spouse, it can be wrenching to assume the role of an authority figure and apply

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pressure. As for friends and coworkers, we fear to tread where we are not invited. Because we know from experience that, like Del, most casual substance users do not develop serious problems, we stand on the sidelines and live in hope. Again like Del, who once drove drunk, we may feel reluctant to confront an issue when there appears to be so little daylight between ourselves and the person who clearly has a problem.

Treating Substance Use Problems: General Approaches

Some treatment principles apply universally, across the board to all substances, but for some substances, including the inhalants, PCP, and hallucinogens, there have no special treatment modalitiesdrugs havent been developed, psychotherapies havent been exploredso we and our patients must rely on general principles. First (and always), take a complete history and obtain a physical examination. Because substance users also use denial, you should interview collateral sources whenever you can. The goals are to be sure that no medical disease has resulted from drug use, to assess how many substances are being abused and to what degree, and to probe the perceived causes of their use. The reasons include peer pressure (All the kids back then were doing it), self-soothing (If I dont have a couple of drinks before bed, I stare at the ceiling and worry), and fun (For the first time ever, I was the life of the party). This information may reveal another diagnosisperhaps depression, social phobia, or another anxiety disorder. When another mental diagnosis (dual diagnosis) is foundwhich is the case in over half the people who misuse drugs and alcoholit can impart another dimension to treatment. Another purpose of the initial evaluation is to assess motivation to change, which is essential to recovery. If your patients commitment to sobriety seems to waver, you might use motivational interviewing to highlight the conflict between life goals and substance usefor example, that you want to be a good provider but, because of drinking, often dont show up for work. The plan for long-term treatment and prevention outlined below assumes that you have already cleared the hurdles of acute intoxication and withdrawal and any emergencies (suicidal ideas and severe infections are just two of the many possibilities). Of course, you should discuss these general treatment steps with your physician, but they are time-honored practices that nearly every clinician will wholeheartedly endorse. Heres a sample of what Id advise my substance-using patient (and the family) to do: Take a week off to organize your thinking. Shield yourself from drug-using friends, but dont be alonekeep your spouse or trusted (non-drug-using) relative or friend with you. Plan how you will change your lifestyle to avoid old habits. Abstinence should be the chief treatment strategy. For decades, people have tried to limit substance use rather than eliminate it completely; for the vast majority of users, this approach simply doesnt work. The future depends on freedom from, not of, substance use. Change the environment. Its far harder to stay off drugs if the person lives or works someplace that encourages their use. It may be necessary to make a physical move away from associates, places, and situations that are reminiscent of drugs. Clean house. Encourage the patient to toss out every bit of drug paraphernalia, every hidden bottle, every last ounce of marijuana. Deal with family problems. Relatives can facilitate the patients recovery by becoming involved in therapy and perhaps confronting their own drug or alcohol issues.

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Join a 12-step program. Although there is little research to prove their effectiveness, I strongly recommend the Anonymous programs (Alcoholics, Narcotics, Cocaine, Pills). They provide role models, support, and fellowship, and they cost nothing but time. Some of the most successful patients are those who commit to attend 90 meetings in 90 days, then follow through. For many, especially those who have no other mental disorders, these programs may work better that conventional psychotherapy. They serve many problems and constituencies around the globe. Some groups discourage all forms of treatment that involve medication, so someone who needs to use pills or patches will have to shop around for a 12step group that meets these particular needs. For some of the same reasons that the 12-step programs work so well, group therapy can increase social support, decrease isolation, and augment education. A proven psychotherapy technique such as cognitive-behavioral therapy is often the best approach. Use antidepressant, antianxiety, or antipsychotic medications only for an independent mental disorder, such as a depression that persists many weeks beyond the time drug/alcohol use stops. If there is another diagnosis, it should probably be treated along with the substance use. Whenever possible, the same clinician should treat both (all) disorders. A big risk for some is furtive usecloset drinking, secretive snorting and the like that eludes detection. If that has been the history, drug screening may help the patient comply with the program. Some patients even authorize the therapist to report them if a urine tests positive for drugs. The threat of negative consequences (being fired or jailed, losing a professional license) provides a powerful incentive to stop using. Drug-free programs for cocaine and heroin users combine weekly individual counseling, frequent checks of urine specimens, and group meetings daily or several times a week. Some reward compliance with vouchers that can be exchanged for useful products. They may provide transportation to and from shelters, where the patients actually live, and lunch at the program. After several months, patients can graduate to paid work. Therapeutic communities work well for some people. Of these, Phoenix House is perhaps the best known. Patients reside at one of many facilities for 12 to 18 months, receiving education, counseling, individual and group therapy, job training, and work assignments. Though expensive, the cost is usually far less than hospital treatment. Phoenix House allows no substitute drugs, but others, such as the VA domiciliary programs, may be less strict. Once clean and sober, the patients job has only just begun, for relapse is just a swallow away. One of my most successful patients kept a daily to-do list that was always headed, Stay sober. Work to identify cues that can trigger a relapse, for example, moods, specific situations, or being around certain people. The patient will need to learn alternative approaches to these situations. Friends, neighbors, and relatives can be brought into the campaign for sobriety. Even if the patient slips and uses again, it isnt a disaster. Patients slip all the time; its the nature of the disease. Whereas the 12-step programs emphasize how long a person has been sober, even memorializing anniversaries with a cake or some other token of achievement, I prefer to focus on the percentage good time this year as compared to the year before, and the year before that. There is almost always something you can find to feel good about. But above all, dont let a slip serve as an excuse to return to full-scale use.

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TREATING SPECIFIC ADDICTIONS

Listed in descending order of popularity, well next cover the range of abused drugs. Table 5 summarizes some recent data on substance use prevalence.

Nicotine
In terms of the misery it wreaks, nicotine is the most deadly addictive substance in the world. The consequences are almost too well-known to list in detaillung cancer, heart disease, and emphysema, for starters. Nearly half of smokers die of illnesses related to their habit, which cuts 7 years off the average life span. Yet the attractions of tobacco useglamour, peer acceptance, feeling grown upare strong enough lures to teens and preteens to make nicotine dependence our most prevalent mental disorder. Nicotine withdrawal symptoms occur in about half of those who quit, peaking at 2-3 days and lasting 3-4 weeks. In the days after she started her cold turkey withdrawal, Miranda felt depressed, irritable, and famished. I was a hungry, cranky witch, she confessed later at a group support meeting; she also described having insomnia, trouble concentrating, and restlessness. After a week, Mirandas GP suggested that she use a nicotine patch, which quieted the withdrawal effects to the point that she could focus during her group support meetings. Of all smokers, each year nearly half try to quit; about half of them eventually succeed, sometimes only after many attempts. Some experts call nicotine the most addictive substance in the world; its legal availability can make it harder for some people to quit than heroin. Data show that using medication with behavior therapy afford the best chance of quitting (and of avoiding weight gain that so often accompanies quitting). As popular as is the patch, some people prefer nicotine gum, spray, or inhaler. Zyban (the antidepressant Wellbutrin) has been shown to reduce weight gain and the craving for nicotine and to slow the onset of relapse; it can also address depression, which is quite likely to recur in a person who was previously clinically depressed and who stops smoking. Some therapists recommend rapid smoking to the point of nausea, but the data dont show advantages over other methods, and it does present health risks.

Sidebar: Smoking Out a Habit

Here are some steps that can help your patients find their way from the tobacco road. Establish a quit date and stop abruptly, if at all possible. Get into a group. Especially if this isnt the first attempt, the support from others facing the same challenges can provide an extra boost. Seek a therapist who can provide behavior therapy (there is good evidence for the effectiveness of reducing the cues that have meant smoking in the past, such as ash trays in the house and after-dinner coffee). Nicotine gum may be especially helpful for those who smoke at certain times of day (for example, after meals, coffee breaks). The 4-mg sticks may be necessary at first; even light smokers tend to find the 2-mg sticks ineffective. Patients who smoke heavily may do better with the patch.

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Because it is irritating, Id avoid the nasal spray, except as a second trial or a helper for the patch. And although the inhaler seems especially inconvenient, at least people dont have to stand outside in the rain to use it. Really heavy smokers may need to combine methods (for example, patch plus spray). And, for someone who has tried repeatedly and failed to quit, you might consider augmenting the patch and behavior therapy with bupropion.

Alcohol
With an onset in the late teens or early 20s, the lifetime risk of serious alcohol use problems is about 10% for men (who also begin earlier), 4% for women; the ratio of male to female heavy users is around 4:1. Substance use is defined by the sort of problems it inflicts upon the individual and those around them. In the case of alcohol, the problems are many and varied. Also of course, the ultimate sequel is death, of which alcoholism is the third leading cause in the United States. Short of that, Shakespeare once observed that people put an enemy in their mouths to steal away their brains. Too bad he didnt also note how far beyond the brain extends the scope of health problems induced by heavy, chronic alcohol misuse. From head to toe, here is a summation of what the Bard missed: Drink-induced amnesia (blackouts), which can occur relatively early in a drinkers history. Wernickes encephalopathy (thiamine) with nystagmus, ataxia, confusion. Korsakoffs syndrome with lasting memory and cognitive impairment (perhaps a third improve with time and adequate nutrition). Dementia. Depression occurs in over half of dependent drinkers. Around 3% kill themselves. [More about this in depression chapter.] Though smoking probably also plays a role, cancer of mouth, tongue, larynx, esophagus, stomach, liver, and pancreas. G-I issues, including gastritis, diarrhea, esophageal varices, and pancreatitis. A wide variety of physical findings, which are both characteristic and classic: palmar erythema, liver enlargement, and bruises from falls; cachexia from malnutrition. Jaundice, ascites, Dupuytrens contractures, testicular atrophy, and male breast enlargement occur late. Impotence. Fetal alcohol syndrome: Low IQ, facial abnormalities (small circumference, small midface, epicanthic folds, indistinct philtrumthe midline vertical groove running from nasal septum to mid-upper lip). It occurs especially when a pregnant woman drinks in binges, which induce rapid rise in blood alcohol. Ataxia and trouble speaking from cerebellar damage. Accidents (which include falls leading to bruises, fractures, subdural hematomas) and over half of all motor vehicle accidents. Finally come social troubles, not as single spies but in battalions: employment problems (absence, lateness, loss of job), marital separations, divorce, arrests, alienation from friends and family.

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And Ye Olde Stratford Lab would have verified that, in most alcoholics, MCV and GGT (gamma-glutamyl transferase) are elevated. The GGT changes rapidly enough that it can be used to monitor ongoing abstinence. Withdrawing from heavy alcohol use General management of alcohol withdrawal includes adequate hydration, food, vitamins (especially Thiamine 100 mg IM, if the patient cannot swallow tablets), and benzodiazepines such as 2550 mg chlordiazepoxide qid, with a 5-day taper. Often, withdrawal can be done on outpatient basis, especially if this has worked previously, but hospitalization will be needed if the patient cannot comply, there are no supports at home, or complications obtain such as other psychiatric illnesses. A heavy drinker like Stanley could experience a number of typical withdrawal symptoms: Tremors Withdrawal shakiness (the shakes) begins after 1218 hours and peaks between 2448 hours. Severely affected patients may require help even to drink a glass of water without spilling. Tremor may be joined by other symptoms that include sweating, insomnia, nausea or vomiting, rapid heartbeat, agitation, and anxiety. With or without treatment, simple withdrawal shakiness subsides after about a week, though some require a benzodiazepine such as chlordiazepoxide (Librium), perhaps in heavy doses, to prevent even more serious withdrawal symptoms. There are several of these. Seizures Long-term heavy drinkers are especially prone to withdrawal seizures, which typically beginning 738 hours after the last drink. Other than short-term use of benzodiazepines, they dont require anticonvulsants, though a neurological consultation would of course be in order. Delirium tremens (DTs) Withdrawal seizures alert us to the possibility of delirium tremens, which occurs in about 5% of hospitalized alcoholics. This is a withdrawal delirium whose symptoms include insomnia, disorientation, and illusions/hallucinations. Symptoms of marked autonomic instability include fever, tachycardia, elevated blood pressure. The classic image is of the patient who lies in bed, picking at the bedclothes with tremulous fingers, and talking to animals or Lilliputian people lined up on the windowsill. DTs lasts about 3 days, up to a week. To reduce agitation, seclusion may be necessary, though adequate lighting will help reduce visual misinterpretation (illusions); some patients will require restraint. A typical drug regimen would be 10 mg of diazepam IM, followed by 5 mg every 515 minutes until agitation recedes. Diazepam can then be tapers over the next few days. Severe hallucinations may require a low dose antipsychotic such as haloperidol. In the old days, death ensued in up to 15%; with good care, nearly everyone survives today. Hallucinosis Alcoholic auditory hallucinosis is uncommon, but dramatic. As opposed to the delirium of DTs, these withdrawal hallucinations are auditory and occur in the context of a clear sensorium. Beginning within 48 hours of the last drink, the patient hears voices that may be threatening, and reacts accordingly. Duration is about a week. Rehabilitation and relapse A person with other medical problems or a past history of severe withdrawal symptoms may require hospitalization for several days. However, decades of research have produced no conclusive evidence that inpatient care improves outcome, unless there are serious withdrawal symptoms. A healthy person who isnt heavily dependent, like Eva, may be able to stop with mild symptoms, at most.

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Three drugs can help maintain sobriety: Acamprosate (Campral), naltrexone (ReVia), and disulfiram (Antabuse). Acamprosates mechanism of action isnt exactly known; it may reduce the dysphoria and sleep disorders that accompanies a heavy drinkers prolonged withdrawal from alcohol. Naltrexone, which blocks brain opioid receptors, has been used for years to combat acute narcotic overdose; it has been found to decrease alcohol craving and euphoria. There is some evidence that two drugs taken together are more effective than either taken individually. Disulfiram causes the body to metabolize alcohol into acetaldehyde, which induces almost immediate nausea and other physical symptoms. The risk of toxicity largely causes clinicians to avoid its use anymore, but it can help prevent slips in someone who is well motivated. As for therapy: although nonspecific psychotherapy hasnt proven very helpful, cognitivebehavioral therapy has. In addition, some patients may benefit from learning social and coping skills. The relapse rate for dependent drinking approaches 50%, especially in first 6 months. But the likelihood of eventual success improves with treatment and stable relationships and the responsibility of a job, less severe comorbid disorders, lack of antisocial personality disorder, and no family history of alcoholism. Should someone who uses both tobacco and alcohol heavily try to quit them at the same time? There are two points of view, neither of which is backed by much science. One argues that quitting alcohol alone is hard enough and that the social and physical effects of alcohol are more immediately destructiveso keep on smokin. The other points out that drinkers often smoke, so that stopping both should reduce the cues of one that stimulate use of the other. Personally, Id work first on the more immediately destructive alcohol.

Marijuana
The upper leaves, flowering tops, and stems of cannabis sativa are made into cigarettes, and the smoke is inhaled deeply and held in the lungs as long as possible to absorb the maximum possible amount of THC (delta-9-tetrahydrocannabinol). Effects in a few (10-30) minutes, lasts 2-4 hours. Half-life ~2 days. Those who dont smoke sometimes eat it in brownies, in which case the onset is slower, but the effects more powerful. Hashish is the dried resinous exudate that collects on the tops and undersides of leaves of female plants. Although worldwide marijuana is the most commonly used of all illegal drugs, over the past two decades, the percentage of teenagers who have tried marijuana in the past year has remained relatively stable at about 35%. Marijuana is used regularly by 20 million or more Americans; half of high school students have tried it. Robin liked marijuana because it made her feel relaxed and contented. After smoking, she would sit back and enjoy dreamy fantasies, during which time seemed to stand still. It reduced her sexual inhibitions like alcohol, but without the hangover. Marijuana is most commonly used like alcoholto facilitate sociability, perhaps a few times in a month. Although any smoking is bad for your lungs, occasional use is relatively harmless certainly, far less a problem than most other illegal (and some legal, see Sidebar) drugs cause. Only rarely are there untoward mental or physical effects. Then, anxiety may necessitate treatment with diazepam. However, heavy use causes whats called the amotivational syndromeapathy, poor concentration, social withdrawal, and loss of interest. In teenagers, heavy use can slow emotional and social development. Marijuana is acutely dangerous if youre pregnant, nursing, have heart

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or lung disease. or driving a car. Although there is no actual withdrawal syndrome, frequent users may feel irritable or have trouble sleeping; anxiety symptoms during use or in a flashback are by no means rare. Most marijuana users probably dont need treatment any more than people who drink alcohol occasionally. That can make it hard to persuade your teenage patient that there is a problem. If marijuana is used frequently, to the exclusion of other activities, group therapy that focuses on drugs probably helps most; benzodiazepines may occasionally be needed short-term to deal with anxiety. Although it has been argued for years that marijuana is a gateway drug that leads to the use of other, more dangerous substances, no cause-and-effect relationship has ever been satisfactorily demonstrated. The vast majority of people, like Robin, dont go on to abuse other drugs. A better case for gateway status can be made for tobacco.

Cocaine
For millennia, indigenous peoples have chewed coca leaves as a stimulant, but westerners first used cocaine a little over 100 years ago. Perhaps a quarter of 21st-Century young people have tried it. In his third year of college, Terry started using cocaine occasionally with friends. It seemed to enhance his social life (he felt bright and witty and had dynamite sex). For a semester, he used it every week or two without problems, but during summer vacation, he smoked crack again and again, until his supply was gone. Then he would fall into a depressed torpor, with dreams of destruction so realistic he would awaken screaming. After a few days, he would rouse himself and start using again so that once more he could feel wonderful and self-confident. Cocaine can be swallowed, snorted, inhaled, or injected IV; famously, at the dawn of the 20th century, it was the eponymous ingredient of Coca-Cola. Until the 1970s, it was little abused in the United States. Heated with sodium bicarbonate, cocaine yields a hard white mass that makes a crackling sound when smoked, hence the term crack. Crack is cheap and powerful, and has been wildly popular since the 1980s; as a smokable, it is safer to use than freebase yet also produces a powerful rush of euphoria. Consult DVDs of the TV series The Wire for details. Especially when smoked or injected, cocaine creates a powerful rush of pleasure, elevating mood and increasing alertness and confidence. (Users sometimes intensify their experience by adding other drugscocaine plus heroin, a combination called a speedball, has been implicated in numerous deaths.) Cocaine is the most powerful reinforcer of drug-taking behavior known. Laboratory rats prefer it to food, water, and the company of other rats; given free access, theyll use it until they die of starvation. Human use is nearly as devastating. Though usually intermittent at the start, users (like Terry) escalate to intense runs, during which they consume the drug several times an hour, until it is gone. Haptic (tactile) hallucinations can be experienced during cocaine intoxication. Withdrawal is extremely rapid, generally less severe than with opioids or sedatives, and usually requires no special treatment. However, the accompanying depression can be so profound that the person will do just about anything to escape. Hospitalization may be necessary for someone who is suicidal, severely depressed (sometimes psychosis supervenes), or who has had previous unsuccessful attempts at rehabilitation. It may take weeks for thinking, mood, and sleep to normalize. Cocaine produces intense devotion and high recidivism; chronic use causes long-lasting changes in the brain and memory loss. It is an

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irony that Sigmund Freud once recommended it as a treatment for alcohol or morphine addiction. (You wont find that featured in the psychoanalytic literature.) Education or pressure from relatives or employers can motivate some people who are not heavily dependent to give up the habit. One study suggests that heavy users may improve with the combination of group and individual drug counseling based on 12-step programs. Relapse prevention therapy (see page *) has been especially successful. Some addicts (and their therapists) swear by earlobe acupuncture; in 2000, a controlled study found it better than two other treatments, but other studies have failed to find any advantages. Terry joined Cocaine Anonymous, and his parents paid for a course of RPT. He recovered, though it took more than a year, and even now he sometimes thinks how wonderful he would feel if he could smoke a single rock of crack.

Amphetamines and Other CNS Stimulants

First synthesized in 1887, the amphetamine molecule languished unappreciated until the early 1930s, when it was marketed as Benzedrine in an inhaler for relief of nasal decongestion. (It was sold without prescription for that purpose until 1965, by which time its potential for abuse had become too great to ignore.) In 1937, Charles Bradley found that amphetamine caused nearly half of behavior-disordered children improved and also showed an improvement in school performance. Clinicians also prescribed amphetamines for disorders as widely varying as impotence and appetite control. From 1942 until his death, Hitler took daily amphetamine injections, which may have affected his conduct of the war. Structurally related to adrenaline, amphetamines today are prescribed for attentiondeficit/hyperactivity disorder in children and narcolepsy in adults, and they are even occasionally useful in depression. Now used for many years by psychiatrists and other physicians for AD/HD, narcolepsy, and (sadly) weight loss, dextroamphetamine is the perhaps best-known of these compounds. The symptoms of intoxication and withdrawal are nearly identical to those of cocaine (see Table). Withdrawal from low doses yields relatively brief fatigue; from higher doses, users become restless, talkative, irritable, and preoccupied with getting more drug. Paranoia and overt psychosis, even death (from stroke or heart failure) sometimes ensue. What do these drugs so appeal to recreational users? They fend off fatigue, making them attractive to truckers and others who drive for a living. Others use them to produce euphoria, perhaps moving on to very high doses, often by inhaling. Users feel strong, smart, and sexy, leading to speed runs of days or weeks, punctuated by periods of crashing. Experienced users sometimes add sedatives or alcohol to moderate the effects. Obtaining amphetamines can occupy a persons entire attention, obliterating all other considerations and responsibilities, including jobs and children. Many occasional users stop without treatment; hospitalization is indicated only if the person becomes severely depressed, psychotic, violent, or the intake is far beyond control. General treatment approaches can liberate many users, though it takes nearly 2 years, on average, to get clean and stay that way. Methamphetamine The chemical structure of methamphetamine is identical to amphetamine except for a methyl group clinging to the nitrogen. The d-isomer, legally marketed as Desoxyn, is prescribed for AD/HD and exogenous obesity. (The l-isomer possesses little central effect; it is a vasoconstrictor used in Vicks and other nasal decongestants. In the United States, the generic

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term used is levmetamfetamine, so as not to raise the alarm of prospective cold sufferers. PR rules!) Despite its availability through legal channels, methamphetamine is notoriously popular with kitchen chemists. Because it can be made from readily available materials, Oregon and other jurisdictions have relegated ephedrine and pseudoephedrine to behind-the-counter availability. Methamphetamines central effects are even more pronounced that those of amphetamine. Known on the streets as crank, it can produce a severe psychosis that begins hours to days after the onset of heavy use. The symptoms are mainly positive, especially visual hallucinations and nonbizarre paranoid delusions. As you might imagine, these patients are typically agitated and may require antipsychotic medication. Flashbacks also occur. In 2007, a young homeless man named Timothy Waddell beat to death Tom Green, the former mayor of Cave Junction, Oregon. Waddells defense was that of methamphetamine-induced psychosis: high on crank, he heard voices and believed that Green was conspiring with the CIA to have him killed. Ironically, Green himself had at one time worked as a chemist.

Hallucinogens
The ability of natural substances (such as mescaline and the fly agaric mushroom) to produce hallucinations has been recorded throughout history. Nearly 100 such plants have been recognized in the Western Hemisphere alone; some of these traditional botanicals, such as peyote, provide the basis for religious rituals in indigenous populations. Not everyone has a green thumb, so it is perhaps not surprising that would-be users have turned to chemistry to meet their needs. For example, Albert Hofmann synthesized lysergic acid diethylamide (LSD) in 1938 from ergot alkaloid, then set it on a shelf. It wasnt until five years later that he returned to discover its psychedelic properties. It is so easily made in home laboratories, hence so cheap, that it has found a wide clientele. LSD is perhaps 5000 times as potent as mescaline, many users value it for its rapid onset of mild euphoria and sensory distortions. During her dozen or so experiences with LSD in college, Miriam found that colors seemed brighter, sounds clearer, tastes sharper than normal. She always knew that these sensations werent real, and she had never experienced one of those bad trips that a friend once describedhe was terrified, feared he was going insane when he seemed to melt into the boundaries of the universe. That frightened her into quitting. For several months afterwards, Miriam would occasionally see bright colors around the edge of the paper she was writing on, and once she thought that people she encountered at the mall were automatons. It wasnt scary, but I sure wanted it to go away. With its duration of effect 812 hours, the LSD experience usually resolves spontaneously after just a few hours. When high, the user should avoid stimulants, emotional stressors, marijuana, and over-the-counter drugs. There are no withdrawal symptoms as such, though Klonopin or Valium may occasionally be needed to calm someone who is coming down from a bad tripas with Miriams friend, it can occasionally cause marked anxiety and paranoia. Because frequent use weakens its effects, most people dont use LSD day after day, so there is little tendency toward dependence. When patients seek treatment, it is usually for depression, anxiety, psychosis, or suicidal ideas. Like Miriam, half or more of frequent users report flashbacksaspects of a previous trip replay themselves spontaneously, without further drug use. If hallucinations persist, antipsychotic agents may be necessary. Then an unresolvable

Substance Misuse argument often erupts: was the long-term psychosis caused by the drug, or would it have occurred anyway? Most experts would vote the latter belief. An overdose can cause fever, arrhythmia, tachycardia, dehydration, and even death.

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MDMA (Ecstasy) Though actually an amphetamine derivative (3,4-methylene dioxy methamphetamine), MDMA is classified with the hallucinogens. One of the so-called designer drugs,* it makes people feel euphoric and close to others, with short-term amnesia followed by restlessness and general discomfort. Jenny encountered Ecstasy at an all-night rave party, when she accepted a drink from someone she didnt know. At first, it boosted her self-confidence so high that she grabbed the microphone and started to sing. Then someone grabbed her and hustled her into the cool-down room, where she gradually succumbed to anxiety bordering on panic, followed by depression. Her drowsiness, trouble concentrating, and fatigue lasted for several days but subsided without any specific treatment. She was lucky: a 2001 study found that MDMA users can suffer long-term cognitive impairment.

Designer drugs are chemicals that have been manufactured to get around substance use laws. Often, these are minor variants of amphetamine or opioidse.g., alpha-methylphentanyl (China White). One, MPTP, has caused severe parkinsonism in some users after just one hit.

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Sidebar: Drug schedules in the United States

Since 1970, through the Controlled Substances Act the Federal Drug Administration has regulated the manufacture, importation, distribution, possession and use of certain drugs. The act has been amended several times in the past 40 years.
Misuse potential Accepted med. use? Dependenc e: Use may lead to Legally available? Refills Sample items Schedule I* High No Schedule II High Yes Severe physical or psychological Schedule III Less than I/II Yes Moderate or low physical or high psychological Rx only 5x in 6 months anabolic steroids; buprenorphine; dihydrocodeine; ketamine; Xyrem (GHB) for treating narcolepsy; paregoric; dronabinol (Marinal), a synthetic form of THC Schedule IV Lower than III Yes Limited physical or psychological relative to III Rx only 5x in 6 months Benzodiazepines; zolpidem and other Z sleepers; propoxyphene (Darvon); phenobarbital and other longacting barbiturates; pentazocine; Modafinil Schedule V Lower than IV Yes Limited physical or psychological relative to IV Only for medical purposes * * Codeine preparations, e.g., Robitussin A-C; difenoxin e.g. Motofen; opium preparations such as Kaolin Pectin P.G.

No Gammahydroxybutyric acid (GHB); heroin; cannabis (!); MDMA (Ecstasy); psilocybin (mushrooms); LSD; methaqualone; bufotenin (originally extracted from toad venom)

Rx only, 30 days** no Cocaine (topical); methylphenidate (Ritalin); opium and its tincture, laudanum; methadone; fentanyl; amphetamine salts (Adderill) for ADHD; dextroampheta-mine; hydrocodone (dilaudid); codeine; secobarbital and other short-acting barbiturates (e.g., pentobarbital); PCP,

*Schedule I: In addition to above criteria, these substances have a lack of accepted safety for use of the drug or other substance under medical supervision" whatever that may mean. **except for cancer patients and burn victims. Here, however, is an alternative view from a recent Lancet article* on the relative harm of 20 drugs. The authors posited 3 categories of harm: Physical, which includes acute, chronic, and intravenous use; the tendency to induce dependence, which includes the intensity of pleasure, psychological dependence, and physical dependence; and the effect of use on families, communities, and society, including intoxication, other social harms, and health-care costs. Harm was assessed using Delphic principles, in which each rater scores each drug independently, then the group discusses the findings, and raters are then given the opportunity to changes their individual ratings.

Nutt D, King LA, Saulsbury W, Blakemore C: Development of a rational scale to assess the harm of drugs of potential abuse. Lancet 2007;369:1047-53.

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Overall harm
Heroin Cocaine Barbiturates Street methadone Alcohol Ketamine Benzodiazepines Amphetamine Tobacco Buprenorphine 2.77 2.30 2.08 1.94 1.85 1.74 1.70 1.66 1.62 1.58 Cannabis Solvents 4-MTA LSD Methylphenidate Anabolic steroids GHB Ecstasy Alkyl nitrites Khat*

Overall harm
1.33 1.27 1.27 1.23 1.18 1.15 1.12 1.09 0.92 0.80

Sedatives
With symptoms similar to alcohol, the criteria for intoxication and withdrawal are identical. Barbiturates and other dangerous sedatives were heavily abused in the 1960s, but strict government controls have led to marked declines in their misuse. Still, the danger of death by respiratory depression is attested by Marilyn Monroe, Charles Boyer, Jim Hendrix, Judy Garland, and Princess Leila Pahlavi of Iran, all of whom died as a result of using secobarbital or some other barbiturates, often in combination with alcohol or other drugs. On the other hand, for a variety of indications, benzodiazepines have been hugely popular, especially with the over-55 crowd. For the most part, benzodiazepines are used appropriately, and those who do misuse them often use other drugs as well. Rarely lethal, even in massive overdose, the symptoms of benzodiazepine misuse are far less severe than those of most other drugs, and the response to treatment is far better. Again, intoxication and withdrawal are symptomatically very similar to alcohol; withdrawal can precipitate seizures and, in a small percentage, even death. A patient who has taken a benzodiazepine longer than 2 weeks should be tapered; start with a ten to 20 percent decrease over the reported daily dose and observe for signs of withdrawal. Reduce by a third on the second or 3rd day; if tolerated, reduce 10-20% further every few days. Mostly, a longer-acting drug (such as diazepam) is used, though some clinicians will taper with the actual drug the patient was using. Patients with a year or more of use may require months for their taper. Studies show that most patients can come off benzodiazepines successfully, in some cases with less anxiety that when on the drug. Carbamezepine 400 mg/day (either bid or at bedtime( may help relieve symptoms of withdrawal; taper it after the benzodiazepine is gone. The general steps outlined above can help most long-term benzodiazepine users successfully stop and stay off. Because many patients are prescribed benzodiazepines for anxiety and other disorders, adequate substitute treatment (such as psychotherapy or antidepressant medication) is extremely important.
*

Tropical flowering plant found in East Africa and the Arabian peninsula. It contains the alkaloid cathinone, an amphetamine-like stimulant that causes anorexia, euphoria, and excitement.

Substance Misuse Rohypnol In recent years, the benzodiazepine Rohypnol (flunitrazepam) has become notorious as the date rape drug. Legally prescribed for sleep in many countries, so-called roofies have been smuggled into the United States and used, often with alcohol, to increase sexual compliance and reduce memory in unsuspecting victims. The last thing I remember was swallowing the drink Ronnie gave me, Cynthia told the policewoman who interviewed her. A few minutes later I felt dizzy and sick to my stomach, and then I must have passed out. I think I woke up once, and he was raping me, but I couldnt be sure. The next clear memory I have is waking up in his bed.

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Whether facilitated by rohypnol or some other drug (evidence suggests that other benzodiazepines are about as likely to cause mischief), date rape can be best prevented by a combination of education and vigilance. Patients (and their doctors!) should avoid punch bowl concoctions. Watch your drink being mixed or drink only from a sealed container; and never leave it unguarded, even to use the bathroom. At a party, enlist a friend as a sort of two-person neighborhood watch, each to observe the other for symptoms of appearing too drunk and, if needed, to get the victim to some place safe to recover.

Inhalants
Inhalants present something of a contradiction: illicit drugs of abuse that were perfectly legal when originally sold as fuels, paint thinners, solvents in glues, and propellants for paint, shaving cream, and hair spray. Because they evaporate easily, users absorb them through their lungs, either by bagging (inhaling from a container into which the substance has been sprayed) or huffing (mouth-breathing through a soaked rag). Although the effects are briefa few minutes to under and hourrepeated often enough, either method can keep a user high for hours. Their wide availability and low price make them a natural for kids, especially grade-school and teenage boys, who often use inhalants as a group activity. The risk seems especially high in underprivileged children an in those whose parents use substances. Dudley had huffed model airplane glue for 3 years; he liked the high and the way it made the hours flash past so he didnt think about the way his parents were always fighting. Because these CNS depressants severely reduce the bloods ability to carry oxygen, the inhalants can cause widespread destruction of the bodys tissues, including brain, kidney, liver, and muscle; a few people even die from inhalant use. It is fortunate that few people actually become physically dependent on them. For those who use them only occasionally, education may be all the discouragement needed; the severe dangers of chronic use will make any chronic user want to use all the treatment steps mentioned above as soon as possible. Those who persist should be referred for longer recovery programs that use a variety of treatment modalities.

Opioids
When you hear the word addiction, doesnt heroin usually spring first to mind? Although people can, and do, misuse any of the opioids*, most addicts prefer heroin. Weekly use usually leads to dependence, the fate of perhaps one in four who ever try it.
*

The opioids include naturally occurring opiates (such as morphine), semisynthetics (such as heroin), and synthetics (including codeine, fentanyl, meperidine, methadone, and oxycodone.

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Although some people begin to use when they are given narcotics for pain, most start in their teens or 20s, perhaps encouraged by peers or as a progression from other drugs. (Healthcare professionals are also at high risk, due in part to the relative availability of drugs.) Although some users snort heroin, injection is the more common way to take the drug; it maximizes the euphoric rush, the sense that all is well. Tolerance begins within a few doses, and pursuit and use (staying well) quickly come to dominate their lives. Beginning within 10 hours or so, withdrawal symptomsnausea, muscle cramps, tearing, insomniaare hardly life-threatening to healthy adults, but they can be extraordinarily uncomfortable and discourage dependent users from quitting.* The typical habit costs $200 a day, which users earn by theft or selling drugs or themselves. There is high comorbidity from other mental disorders and from such physical conditions as HIV and hepatitis C; as you might expect, the overall death rate is enormous, especially from overdose, suicide, and AIDS. Those who genuinely want to rid themselves of heroin dependence must commit to long-term changes of lifestyle, friends, even locationit may be impossible to stay off drugs if exposed to reminders of former lives. The first step is to get off drugs, and to do that may require withdrawal using methadone or clonidine, which can help suppress the aches, insomnia, lethargy, restlessness, and craving. In mild withdrawal, you can use benzodiazepines to aid anxiety and sleep. The medication will be tapered gradually, a process that can take several weeks. Then the problem is to decide how best to prevent relapse. Some manage with drug-free programs, which feature frequent outpatient groups; some move to therapeutic communities for periods as long as 18 months; here they are treated by ex-addicts as well as professionals. Counseling, Narcotics Anonymous, and cognitive-behavioral therapy all seem to help many users. Though I know of no absolute proof of their effectiveness, Id consider any or all in the rehabilitation of an opioid user. Family therapy can help, though its advantage may lie simply in having supportive relatives who are committed to rehabilitation. Ironically, many heroin users require drug maintenance if they are to remain clean. Erik was a 42-year-old Army veteran who had started using heroin with a lot of friends when he was overseas in the army. Back home, his friends all quit, but Eriks paychecks and a lot else continued to go into his arm. He had lasted less than a week in several drug-free programs. Finally reduced to selling drugs and burglarizing cars for stereos, he applied to a VA clinic and began methadone maintenance. On 70 mg a day he rapidly stabilized. Although once or twice he relapsed, as revealed by his urine samples, he admitted his mistakes and redoubled his commitment to staying drug free. Two years later he was still on methadone but otherwise clean and sober, once more gainfully employed. Because of its long half-life, methadone little kick and a slow withdrawal. Thats why many patients can use it successfully to relieve drug craving and keep them from using illicit opioids. The federal government closely regulates maintenance by methadone, which must be given in a licensed treatment program. To qualify for such a program, patients must have been dependent for at least 1 year and failed to quit, using other means. With adequate doses (often 60 mg/day or more), most patients experience decreased illicit drug use, depression, unemployment, and crime.
*

Symptoms of withdrawal are outlined in Table 3. The term cold turkey may derive from the look and feel of a turkey plucked and waiting to be cooked.

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An important negative is that withdrawing from methadone is uncomfortable and can take many months. Without it, 75% or more of patients return to illicit use, so most clinicians argue that there should be no arbitrary limit on length of maintenance. For patients who cant find a methadone program or dont qualify, there are a couple of options. Buprenorphine, a mixed opiate agonist-antagonist with a long half-life, is taken as a sublingual tablet and can be prescribed by individual physicians who have had special training. Both it and methadone work well in adequate doses, though methadone may have the edge in low doses. Naltrexone (ReVia) is an opioid antagonist that blocks euphoria, without which there is less drive to use heroin. Its principal use has been in the treatment of alcohol dependence. There is evidence that any drug is more likely to be successful if combined with a psychosocial treatment. Patients who use both sedatives and an opioid should first be stabilized with methadone, then withdrawn from the sedativeby far, sedative withdrawal is the more dangerous syndrome. The chances of eventually recovering from opioid dependency actually arent bad. Many people shake the habit, even without special treatment. Overall, the most important predictive factor is the strength of motivation. For example, a professional person (read: healthcare worker) whose license to practice depends on remaining clean and sober has a powerful reason to clean up and stay that way; the strict demands of a spouse or partner may serve the same function. Stable employment and supportive relatives generally improve the likelihood of anyones success. And, like most of Eriks friends, soldiers tend to stop using after returning from a combat zone. But for many others, the outlook is less bright. Life crisis or depression often heralds relapse, which is most likely to occur within the first 3 months. Yet, we shouldnt give up on someone who has tried unsuccessfully to quit: multiple treatment attempts can add up, eventually leading to success.

PCP
Judging just by the numbers of patients affected, phencyclidine (PCP, or angel dust) isnt such a serious problem, but if you go by the utter destruction it can cause, PCP is a calamity lying in wait. Smoked, snorted, or swallowed, PCP starts working within 5 minutes and peaks in half an hour. Originally an animal anesthetic, its effects are highly unpredictable. It can produce euphoria or panic, hallucinations and paranoia, drowsiness and disorientation. Nystagmus is characteristic, and convulsions, coma, and eventual death sometimes results from respiratory depression. Most people who use PCP recoverthough one man I knew remained strapped to a hospital bed, hostile and rigid, secluded for weeks at a time because any stimulation launched him into a violent rage. Benzodiazepines and antipsychotics (those that are weakly anticholinergic, such as risperidone or haloperidol) may be useful for agitation, but there is no known, definitive treatment. It has led to chronic psychosis, but of course, that brings up the chronic questions of cause and effect. To ingest this drug voluntarily is the utmost in human folly.

Physicians Approach to the Substance Use Patient (and Family)

Working with the patient Here are some of the precepts I try to keep in mind when working with substance-using patients:

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Practice acceptance, and eschew reproach. Dont express alarm, horror, distaste, and all the other perfectly normal emotions you may be feeling. Your patients have experienced them alltheir own and from family, and they dont need to hear the same thing from you. Dont dismiss treatment options, just because they havent worked in the past. It often takes repeated * runs at the * before *. Other than quitting your substance use, dont make major changes. Specifically, dont change jobs, get a divorce, or move. Ive known people who violated these rules (sometimes all three at once!), and it can lead to disaster. Boredom is an enemy of sobriety. Encourage participation in new activities as a substitute for drug use. Vigorous exercise, for example, produces a natural high without harmful side effects. Repeatedly express your support and belief that treatment can help. A lot of each will be needed to get past the demoralization (Whats the use?) so many drug users experience. Encourage participation in a 12-step program. I always bring up this option earlyand often. Dont argue with someone who is intoxicated. It will happen especially on the telephone when youre on call; a patient will call up with concerns that youve dealt with, or tried to, in the office. Youll get nowhere until the patient sobers up; ask him/her to make a return appointment to see you in the office. Regard slips as an educational opportunity. (Youve had a lapse, not a relapse; and weve identified another situation thats dangerous for you.) Dont measure success by duration of total abstinence but as percent time spent substance free. It is so easy to talk down to a substance user who, after all, uses behaviors that are the acme of the childish and self-defeating. But these patients need to feel more responsible for their own actions, not lessso dont treat users like children. If you cannot get the person completely off drugs or alcohol, do what you can to reduce harm (for example, counsel eating regular meals, taking multiple vitamins, using condoms). Dont hesitate to be frank. Clinicians have the same feelings as anyone else, so we sometimes feel reluctant to bring up discomforting subjects. You dont have to be harsh, or even critical, but a calm, forthright discussion of behaviors and their consequences might help to break through the protective wall of denial your patient has erected.

Working with the family And in talking with your patients relatives and friends, the points I like to cover include: First (I remind them), it isnt your fault. Its hard for anyone to remain strong while feeling guilty. This guilt can be hard to shake, especially when some substance users are adept at putting the blame everywhere but on themselves. Learn all you can about the substance. Read books and magazine articles, attend lectures, surf the Internet. Whenever possible, accompany your relative to medical and counseling sessions. Join an Al-Anon program to learn what other supportive steps might be taken. For kids, theres Alateen. These programs can help relatives cope when feeling worn down by the dayin, day-out behavior that they see as destroying their relationships. Wait until the return of sobriety to resolve differences. When the patient is high is no time for a confrontation it simply wont register.

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Listening to reasons for using doesnt mean that you agree with them. Learn to meet denial or lies with facts, not arguments. The purpose of denial is to avoid feelings of guilt and shame. If relatives can learn to present facts in a calm, friendly manner, it will help to establish them as an allies. Ask relatives to read this sentence until they believe it: Overwhelming evidence proves that substance abusers are sick, not bad. Consider recommending family therapy. It can be a terrific opportunity to deal with enabling (unconsciously shielding someone from the consequences of drug use). Studies show that recovery is strongly reinforced by support of family members, who need to learn that they are not to blame and that their anger at the user is normal. Nonusing spouses should be supported when they contemplate leaving the relationship. Help them learn to explain calmly (when the partner is sober) that the relationship wont last if drug use continues. The consequences of continuing drug use must come across as information, not as a threat. If there has been any history of violence, ensure the safety of all parties, including the spouse, family, and indeed the patient. Someone who remains with an abusive user endangers all the family, and may make treatment seem less urgent. Spouses who want partners to quit using alcohol, tobacco, or drugs must maintain a substance-free home and avoid these substances themselves, even if their own use is moderate. For just one partner to quit while the other continues to use is likely to destroy the sobriety, the relationship, or both. Is the patient worried that their children may take up the use of drugs? The relatives of drinkers tend to drink, but this is a statement, not a life sentence. Education and frank discussion can help sow the seeds of sobriety now. If your patient is pregnant, redouble your efforts to help her avoid all drugs, many of which can seriously affect the survival and health of the developing baby. Prepare the family for depression, irritability, and cravings once their relative is off drugs. Theyll also have to deal with their own resentment.

Substance Misuse Tables

TABLE 1. Symptoms of substance intoxication and withdrawal and presence of dependence and abuse Substance The attraction Reduced inhibitions (including sexual), improved sociability, brightened mood Behavioral/emotional sx during intoxication* Inappropriate sexuality or aggression, labile mood, impaired judgment, impaired job or social functioning Physical/cognitive sx during intoxication 1+ of: slurred speech, poor coordination, unsteady walking, nystagmus,1 poor memory, loss of concentration, stupor or coma Withdrawal symptoms* 2+ of: sweating, rapid heartbeat, tremor, sleeplessness, nausea or vomiting, brief hallucinations, increased activity, anxiety, seizures 2+ of: dysphoria, fatigue, vivid bad dreams, excessive sleepiness or insomnia, increased appetite, psychomotor activity speeded- or slowed *Officially, N/A

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Alcohol, hypnotics sedatives/ anxiolytics

Depend/ Abuse Depend/ Abuse

Amphetamines, cocaine

Elevated mood, increased talkativeness and sociability, alertness, self-confidence, relief from fatigue; some claim improved sexual performance; some inject or inhale cocaine for sudden rush of intense pleasure Reduced fatigue and drowsiness, improved mood and concentration; Legally available everywhere, in many different forms Mild euphoria, sensory distortions

Euphoria, blunted mood, extreme vigilance, interpersonal sensitivity, anger, anxiety, tension, changes in sociability, stereotyped behaviors,2 impaired judgment, poor job or social functioning Clinically important distress or impaired job, school, social, or other functioning

2+ of: dilated pupils, rise or fall in blood pressure or heart rate, chills, sweating, nausea, vomiting, weight loss, agitation, weakness, depressed breathing, chest pain, irregular heartbeat

Depend/ Abuse

Hallucinogens

Depression or anxiety, ideas of reference, persecutory ideas, fears of insanity, poor judgment, impaired job or social functioning Apathy, assaultiveness, belligerence, poor judgment, impaired school, job, or social functioning

5+ of: restlessness, nervousness, excitement, sleeplessness, red face, polyuria, gi upset, muscle fasciculations, rambling speech, rapid or irregular heartbeat, tireless periods, psychomotor agitation Perceptual changes plus 2+ of: dilated pupils, rapid pulse, sweating, irregular heartbeat, blurred vision, tremors, poor concentration

Neither

Caffeine

Inhalants

Giddiness, stimulation, loss of inhibitions, an illusion of strength; they are cheap and legal (hence, available), which appeals to children Relaxed sense of well-being, reduced inhibitions similar to alcohol, dreamy fantasies Initially, glamour, social acceptance; later, relief of withdrawal symptoms

2+ of: dizziness, nystagmus, poor concentration, slurred speech, unsteady walking, lethargy, slowed reflexes, slowed psychomotor activity, tremors, muscle weakness, blurred or double vision, stupor or coma, euphoria Motor deficits, anxiety, Within 2 hours of use, 2+ of: red euphoria, impaired judgment, eyes, increased appetite, dry mouth, social withdrawal, sensation rapid heart rate that time has slowed down N/A N/A

None, though flashbacks (hallucinations that persist after the drug is out of the system) can occur N/A

Depend/ Abuse

Depend/ Abuse

Mariju ana

N/A

Depend/ Abuse

Euphoria, reduced concern for the present, indifference to pain

Opioids

Euphoria leading to apathy, depression, or anxiety; activity level up or down; poor judgment, impaired job or social functioning

Constricted pupils (or dilated if severe overdose) plus 1+ of: sleepiness or coma, slurred speech, poor memory or loss of concentration

4+ of: dysphoria or Depend depression, insomnia, anger, irritability, anxiety, trouble concentrating, restlessness, slowed heartbeat, increased appetite or weight 3+ of: dysphoria, Depend/ nausea, vomiting, Abuse muscle aches, tearing or runny nose, dilated pupils or sweating or piloerection, diarrhea, yawning, fever, sleeplessness N/A Depend/ Abuse

Nicotine

Euphoria, hallucinations, disconnectedness PCP

Assaultiveness, belligerence, impulsiveness, agitation, unpredictability, poor judgment, impaired job or social functioning

2+ of: nystagmus, numbness, trouble walking, trouble speaking, rigid muscles, abnormally acute hearing, coma, seizures

* The symptoms arent caused by a general medical condition nor better explained by another mental disorder. Noted upon cessation or reduction of heavy or prolonged use (or, for opioids, upon taking an agonist)

The symptoms cause clinically important distress or impair social, job, or other functioning.

Substance Misuse Tables

Table 2. Criteria for intoxication with psychoactive substances Alcohol/sedatives, etc. Recent use Some required, eg: Inappropriate sexuality or aggression Labile mood Impaired judgment Impaired job, school, or social functioning Caffeine Recent use >250 mg Clinically important distress or impaired job, school, social, or other functioning Cannabis Recent use Some required, eg: Motor performance deficits Anxiety Euphoria Impaired judgment Social withdrawal Slowed sense of time Cocaine/amphetamines Recent use Some required, eg: Euphoria or blunted affect Hypervigilance Interpersonal sensitivity Anger, anxiety, or tension Changes in sociability Stereotyped behaviors Impaired judgment Impaired job, school, or social functioning Hallucinogens Recent use Some required, eg: Depression or anxiety Ideas of reference Fears of insanity Persecutory ideas Impaired judgment Impaired job, school, or social functioning Inhalants Recent use or exposure Some required, eg: Apathy Assaultiveness Belligerence Impaired judgment Impaired job, school, or social functioning Opioids Recent use Some required, eg: Euphoria, then apathy Depression or anxiety Speeded or slowed psychomotor activity Impaired judgment Impaired job, school, or social functioning During or shortly after use, pupils constricted (or dilated, if severe overdose) During or shortly after use, 1+ of: Sleepiness or coma Slurred speech Impaired memory or attention PCP Recent use Some required, eg: Assaultiveness Belligerence Impulsiveness Speeded psychomotor activity Unpredictability Impaired judgment Impaired job, school, or social functioning

144

Maladaptive psychological/ behavioral changes

Other Other symptoms specifiers

During or shortly During or shortly after use, one or after use, 5+ of: more: Restlessness Slurred speech Nervousness Lack of Excitement coordination Sleeplessness Unsteady walking Red face Nystagmus Urination Impaired Gastrointestinal attention or upset memory Twitching muscles Stupor or coma Rambling speech Rapid or irregular heart rate Tireless periods Psychomotor activity

Within 2 hours of use, 2+ of: Red eyes Appetite Dry mouth Rapid heart rate

None

With With perceptual perceptual disturbances disturbances The symptoms are neither caused by a general medical condition nor are they better explained by another mental disorder.

None

With perceptual disturbances

During or shortly after use, 2+ of: Speeded or slowed heart rate Dilated pupils Blood pressure or Chills or sweating Nausea or vomiting Weight loss Speeded or slowed psychomotor activity Muscle weakness, depressed breathing, chest pain, or irregular heartbeat Seizures, confusion, distorted voluntary movements or muscle tone, or coma With perceptual disturbances

During or shortly During or shortly after after use, use, 2+ of: perceptual changes Dizziness During or shortly Nystagmus after use, 2+ of: Lack of coordination Dilated pupils Slurred speech Rapid heart rate Unsteady walking Sweating Lethargy Palpitations Slowed reflexes Blurred vision Slowed psychomotor Tremors activity Lack of Tremors coordination Muscle weakness Blurred or double vision Stupor or coma Euphoria

Within 1 hour of use, 2+ of: Nystagmus Heightened blood pressure or heart rate Numbness or decreased pain response Trouble walking Trouble speaking Rigid muscles Coma or seizures Abnormally acute hearing

None

None

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Table 3. Criteria for substance withdrawal Alcohol/sedatives, &c Heavy/prolonged use before cessation or reduction Cocaine/ amphetamines Heavy/prolonged use before cessation or reduction Hallucinogens [See table footnote] Nicotine Daily use for several weeks before cessation/ reduction Opioids

Use

Specific Symptoms

General criteria Other

Several weeks of heavy use before cessation/ reduction, or use before using an antagonist Within hours to a Within hours to Within 24 Within few days, 2+ of: a few days, hours, 4+ of: minutes to a Sweating or rapid dysphoric mood Dysphoria or few days, 3+ heartbeat plus two or depression of Trembling of more: Sleeplessness Dysphoria hands Fatigue Anger, Nausea or Sleeplessness Vivid bad frustration, or vomiting Nausea or dreams irritability Aching vomiting Brief Increased or Anxiety muscles hallucinations or decreased sleep Trouble Tearing or illusions Heightened concentrating runny nose Speeded appetite Restlessness Dilated psychomotor Speeded or Slowed heart pupils, erect activity slowed rate hairs, or Grand mal seizures psychomotor Increase in sweating Anxiety activity appetite or Diarrhea weight Yawning Fever Sleeplessness The symptoms cause clinically important distress or impair social, job, or other functioning. The symptoms are neither caused by a general medical condition nor are they better explained by another mental disorder. With perceptual disturbances

Note. Although it occurs after a person has ceased use of LSD or another hallucinogen, hallucinogen persisting perception disorder (flashbacks) isnt actually a disorder of withdrawal. It consists in the reexperiencing of at least one of the symptoms of perception that occurred during hallucinogen intoxication (such as flashes of color, trails of images, afterimages, halos, perceptions of objects as larger or smaller than they actually are, geometric hallucinations, and false peripheral perception of movement). The criteria listed as "Other" in the table body also apply to this disorder.

Substance Misuse Tables

Table 4. Criteria for substance-related mental disorders Disor- Delirium, onset Intoxication der or Withdrawal (I or W) Reduced level of consciousness and difficulty focusing, shifting, or sustaining attention Cognitive change (deficit of language, memory, orientation, perception) that dementia cant better explain Sx develop rapidly (hours to days) and tend to fluctuate during the day Main symptoms History, PE, or lab data suggests symptoms developed 1) during substance intoxication or were caused by medication use (for intoxication delirium) or 2) shortly after substance withdrawal (for withdrawal delirium) Persisting Persisting Dementia Psychotic Disorder Mood Disorder Anxiety Disorder Sleep Sexual Dysfunctioning Disorder Amnestic Disord Deficits of Persistence of Clinically important Impaired Prominent Prominent anxiety, A sleep thinking, as memory (cant delusions or (1): Depressed compulsions, problem sexual dysfunctioning shown by both: mood or notably dominates the clinical learn new hallucinations obsessions, or panic serious information or (1) impaired (except those for decreased attacks enough to picture. memory; (2) 1+ cant recall which patient has interest or warrant No other sexual information of aphasia, insight) pleasure in clinical dysfunction better apraxia, agnosia, previously nearly all attention explains these impaired learned). activities; and/or symptoms. executive (2) elevated, functioning irritable, or expansive mood Symptoms don't occur solely in the context of delirium (or, for persisting amnestic disorder, dementia). History, PE, or lab data shows that substance History, PE, or History, PE, or lab data suggests either that symptoms developed within 1 month of substance intoxication use fully explains the lab data or withdrawal, or that they are caused by medication use. symptoms; either 1) suggests lasting The effects last Another, non-substance-induced [psychotic] [mood] [anxiety] [sleep] disorder Symptoms start within effects of longer than doesn't better account for symptoms. a month of substance use typical effects of intoxication, or 2) have probably substance medication use causes caused the intoxication or them symptoms withdrawal Each symptom causes clinically Symptoms cause clinically important distress or impair work, Symptoms cause important distress or impaired school, social, or personal functioning. marked distress or functioning, and each shows a decline interpersonal problems in level of functioning Also code substance dependence, if appropriate ? Substance With Onset During Intoxication or During Withdrawal Code: With delusions, with hallucinations Alcohol Amphetamines Cannabis Cocaine Hallucinogens Inhalants Opioids PCP Sedatives, hypnotics, anxiolytics Other/unknown With depressive manic or mixed features. Substance With Onset During Intoxication or During Withdrawal Alcohol Amphetamines Cocaine Hallucinogens Inhalants Opioids PCP Sedatives, hypnotics, anxiolytics Other/unknown With generalized anxiety, panic attacks, obsessive-compulsive symptoms, or phobic symptoms Substance With Onset During Intoxication or During Withdrawal Alcohol Amphetamines Caffeine Cannabis Cocaine Hallucinogens Inhalants PCP Sedatives, hypnotics, anxiolytics Other/unknown Insomnia, Hypersomn ia, Parasomnia , or Mixed type Based upon main features: With impaired desire, with impaired arousal, with impaired orgasm, with sexual pain. Also whether: With onset during intoxication Alcohol Amphetamines Cocaine PCP Sedatives, hypnotics, anxiolytics Other/unknown

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Inclusions, exclusions, Specify

Intoxication or Withdrawal delirium Substance(s) involved

Applies to:

Alcohol (I & W) Amphetamines (I) Cannabis (I) Cocaine (I) Hallucinogens (I) Inhalants (I) Opioids (I) PCP (I) Sedatives, hypnotics, anxiolytics (I & W) Other/unknown (I & W)

Alcohol Sedatives, hypnotics, anxiolytics Other/unknown

Alcohol Inhalants Sedatives, hypnotics, anxiolytics Other/unknown

Alcohol Amphetamin es Caffeine Cocaine Opioids Sedatives, hypnotics, anxiolytics Other/unkno wn

Substance Misuse Tables

Table 5 Use in millions Substance Tobacco Alcohol Marijuana and hashish Cocaine and crack Tranquilizers Hallucinogens and PCP Stimulants Inhalants Sedatives Heroin Any illicit drug *Heavy alcohol users (5+ drinks/day, 5+ days/month) Lifetime use in millions (%) 157.5 (70.5%) 180.8 (80.0%) 76.4 (34.3%) 25.4 (11.2%) 13.0 (5.8%) 26.1 (11.7%) 14.6 (6.6%) 16.7 (7.5%) 7.1 (3.2%) 2.8 (1.2%) 86.9 (38.9%) Previous month in millions (%) 65.4 (29.3%) 12.5 (5.6%)* 10.7 (4.8%) 1.2 (0.5%) 1.0 (0.4%) 0.98 (0.4%) 0.79 (0.4%) 0.62 (0.3%) 0.17 (0.1%) 0.13 (0.1%) 14.0 (6.3%)

147

Review
While he was still in high school, Jerralds drinking was already getting out of hand. Hed had a couple of close calls when driving, once skidding on a mountain road, coming to rest backwards on the highway, inches from an unguarded plunge into a canyon. His best friend, Ben, used to say, Ill drink with him, but I wont ride with him. And a couple of times, he hadnt even shown up for an important exam in calculusand he planned to major in math when he hit college. Nonetheless, when the chips were really downas for the SATs, which he acedhe managed to keep his drinking from getting out of hand. He escaped from high school as a covaledictorian of his 550-student high school class. In college, he found that he stayed sober enough to drive even when he had drunk a 6-pack of beer in as little as an hour. But he kept a tight lid on how often he drankno more than once or twice a monthbecause he knew he had to make the grades to get into medical school. I did do a little blow, now and then, when I was in funds. Just like the president. However, he sometimes found that hed gone through all the crack hed been saving for a big party. The last half of his senior year, after hed gotten the acceptance letter to medical school, his studying dropped pretty close to zero. I was pretty busy trying to score some weed. The second year of medical school, his girlfriend moved out (Ive begged you to stop, but you care more for Jim Beam than you do for me, she had complained more than once.) Apparently, drinking also took up a lot of the time he should have been studying pharmacologyhe failed it outright, and was told hed have to repeat his sophomore year. You know, more than once Ive tried to cut down, he told his roommate morosely. Remember when I went cold turkey before the biochem final and got the shakes? 1. 2. 3. 4. What would you say Jerralds diagnosis was, as described in high school? [p *] And in college? How would you describe his relationship with substances then? [p *] Finally, diagnosis in medical school? [p *] If he were your classmate, what would you suggest to help Jerrald with his substance problem? (Hint: its biopsychosocial.) [p *] 5. Several features of substance intoxication are common to nearly all the drugs listed above. What are the ones that make them attractive to users? [p *] 6. In working with the family of any substance user, there are a number of issues you can/should address. Name some of them. [p *]

Substance Misuse Tables 7. Discuss Jerralds prognosis for a full recovery from [whatever is correct diagnosis might be]. [p *]

148

Further Learning
No one does it better than a couple of oldies Days of Wine and Roses Movie: Barfly (the challenge is not to read this as an adverb signifying emesis)

More Further Learning Dickens Old Curiosity Shop. The grandfather is a classic, pathological gambler; leads to death of Little Nell.