198 APPROACH TO THE PATIENT WITH PSYCHIATRIC SYMPTOMS
Harrison’s Manual of Medicine
APPROACH TO THE PATIENT WITH PSYCHIATRIC SYMPTOMS
Major Psychiatric Disorders (Axis I Diagnoses)
Mood Disorders (Major Affective Disorders)
Schizophrenia and Other Psychotic Disorders
Personality Disorders (Axis Ii Diagnoses)
Cluster A Personality Disorders
Cluster B Personality Disorders
Cluster C Personality Disorders
Disorders of mood, thinking and behavior may be due to a primary psychiatric diagnosis (DSM-IV* Axis I major psychiatric disorders) or a personality disorder (DSM-IV Axis II disorders) or may be secondary to metabolic abnormalities, drug toxicities, focal cerebral lesions, seizure disorders, or degenerative neurologic disease. Any pt presenting with new onset of psychiatric symptoms must be evaluated for underlying psychoactive substance abuse and/ or medical or neurologic illness. Specific psychiatric medications are discussed in Chap. 199. The DSM-IV-PC (Primary Care) Manual provides a synopsis of mental disorders commonly seen in medical practice.
MAJOR PSYCHIATRIC DISORDERS (AXIS I DIAGNOSES)
Mood Disorders (Major Affective Disorders)
MAJOR DEPRESSION Clinical Features Affects 15% of the general population at some point in life and extracts high disability and societal cost. Diagnosis is made when a depressed/irritable mood or a lack of normal interest/ pleasure exists for at least 2 weeks, in combination with four or more of the following symptoms: (1) change in appetite plus change in weight; (2) insomnia or hypersomnia; (3) fatigue or loss of energy; (4) motor agitation or retardation; (5) feelings of worthlessness, self-reproach, or guilt; (6) decreased ability to concentrate and make decisions; (7) recurrent thoughts of death or suicide. A small number of pts with major depression will have psychotic symptoms— hallucinations and delusions—with their depressed mood; many present with a “masked depression,” unable to describe their psychological distress but with multiple diffuse somatic complaints.
Onset of a first depressive episode is typically in the thirties or forties, although major depression is found in children and adolescents as well as geriatric pts. Untreated episodes generally resolve spontaneously in 5–9 months; however, a sizeable number of pts suffer from chronic, unremitting depression or from partial treatment response. Half of all pts experiencing a first depressive episode will go on to a recurrent course, with a second episode occurring within 2 years. Untreated or partially treated episodes put the pt at risk for future problems with mood disorder. A family history of mood disorder is common and tends to predict a recurrent course. Major depression can also be the initial presentation of bipolar disorder (manic depressive illness).
Suicide Most suicides occur in pts with a mood disorder, and many pts seek contact with a physician prior to their suicide attempt. Physicians must always inquire about suicide when evaluating a pt with depression. Features that place a pt at high risk for suicidal behavior include: (1) a formulated plan and a method, as well as an intent; (2) prior attempts; (3) concomitant alcohol or other psychoactive substance use; (4) psychotic symptoms; (5) older age; (6) male gender; (7) Caucasian; (8) social isolation; (9) serious medical illness; (10) recent loss and/or profound hopelessness.
Pts with suicidal ideation require treatment by a psychiatrist and may require hospitalization. Most other pts with an uncomplicated unipolar major depression (a major depression that is not part of a cyclical mood disorder, such as a bipolar disorder) can be successfully treated by a nonpsychiatric physician. Vigorous intervention and successful treatment appear to decrease the risk of future relapse. Pts who do not respond fully to standard treatment should be referred to a psychiatrist.
Antidepressant medication is the mainstay of treatment; symptoms are ameliorated after 2–6 weeks at a therapeutic dose. Antidepressants should be continued for 9–12 months, then tapered slowly. Pts must be monitored carefully after termination of treatment since relapse is common. The combination of pharmacotherapy with psychotherapy [usually cognitive-behavioral therapy (CBT) or interpersonal therapy (IPT)] produces better and longer-lasting results than drug therapy alone. Electroconvulsive therapy is generally reserved for pts with life-threatening depression unresponsive to medication or for pts in whom the use of antidepressants is medically contraindicated.
BIPOLAR DISORDER (MANIC DEPRESSIVE ILLNESS) Clinical Features A cyclical mood disorder in which episodes of major depression are interspersed with episodes of mania or hypomania; 1–2% of the population is affected. Most pts initially present with a manic episode in adolescence or young adulthood, but 20% present with a major depression. Antidepressant therapy is usually contraindicated in pts with a cyclical mood disorder because it may provoke a manic episode or make the cycles between mania and depression more frequent and more intense (“rapid cycling”). Pts with a major depressive episode and a prior history of “highs” (mania or hypomania—which can be pleasant/euphoric or irritable/impulsive) and/or a family history of bipolar disorder should not be treated with antidepressants but must be referred promptly to a psychiatrist.
With mania, an elevated, expansive mood, irritability, angry outbursts, and impulsivity are characteristic. Specific symptoms include: (1) increased motor activity and restlessness; (2) unusual talkativeness; (3) flight of ideas and racing thoughts; (4) inflated self-esteem that can become delusional; (5) decreased need for sleep (often the first feature of an incipient manic episode); (6) decreased appetite; (7) distractability; (8) excessive involvement in risky activities (buying sprees, sexual indiscretions). Pts with full-blown mania can become psychotic. Hypomania is characterized by attenuated manic symptoms and is greatly underdiagnosed, especially in nonpsychiatric settings. “Mixed episodes,” where both depressive and manic or hypomanic symptoms co-exist simultaneously, are also underrecognized and misdiagnosed.
Untreated, a manic or depressive episode typically lasts for 1–3 months, with cycles of 1–2 episodes per year. Risk for manic episodes increases in the spring and fall. Variants of bipolar disorder include rapid and ultrarapid cycling (manic and depressed episodes occurring at cycles of weeks, days, or hours). In many pts, especially females, antidepressants trigger rapid cycling and worsen the course of illness. Pts with bipolar disorder are at risk for psychoactive substance use, especially alcohol abuse, and for medical consequences of risky sexual behavior (STDs).
Bipolar disorder has a strong genetic component. Pts with bipolar disorder are vulnerable to sleep deprivation, to changes in the photoperiod, and to the effects of jet lag.
Bipolar disorder is a serious, chronic illness that requires lifelong monitoring by a psychiatrist. Acutely manic pts often require hospitalization to reduce environmental stimulation and to protect themselves and others from the consequences of their reckless behavior. Mood stabilizers (lithium, carbamazepine, valproic acid, gabapentin, lamotrigine, topiramate) are effective treatment and are used for the resolution of acute episodes and for prophylaxis of future episodes. Antipsychotic medication, benzodiazepines, and antidepressants such as buproprion may be part of the treatment regimen. As in unipolar depression, rapid therapeutic intervention may decrease the risk of future relapse.
Schizophrenia and Other Psychotic Disorders
SCHIZOPHRENIA Clinical Features Occurs in 1% of the population worldwide; 30–40% of the homeless are affected. Characterized by a waxing and waning vulnerability to psychosis, i.e., an impaired ability to monitor reality, resulting in altered mood, thinking, language, perceptions, behavior, and interpersonal interactions. Pts usually present between late adolescence and the third decade, often after an insidious premorbid course of subtle psychosocial difficulties. Core psychotic features last ³6 months and include: (1) delusions, which can be paranoid, jealous, somatic, grandiose, religious, nihilistic, or simply bizarre; (2) hallucinations, often auditory hallucinations of a voice or voices maintaining a running commentary; (3) disorders of language and thinking: incoherence, loosening of associations, tangentiality, illogical thinking; (4) inappropriate affect and bizarre, catatonic, or grossly disorganized behavior.
Many pts stabilize after the first 5 years of illness. 30–40% show a deteriorating course, but at least 25% do well, especially with early intervention. Females tend to have a later age of onset and a more benign course than males. Comorbid substance abuse is common, especially of nicotine, alcohol, and stimulants.
Hospitalization is required for acutely psychotic pts, especially those with violent command hallucinations, who may be dangerous to themselves or others. Conventional antipsychotic medications are effective against hallucinations, agitation, and thought disorder (the so-called positive symptoms) in 60% of pts but are often less useful for apathy, blunted affect, social isolation, and anhedonia (negative symptoms). The novel antipsychotic medications—clozapine, risperidone, olanzapine, quetiapine, and others—have become the mainstay of treatment as they are helpful in pts unresponsive to conventional neuroleptics and may also be useful for negative and cognitive symptoms. Long-acting injectable forms of haloperidol and fluphenazine are ideal for noncompliant pts. Psychosocial intervention, rehabilitation, and family support are also essential.
OTHER PSYCHOTIC DISORDERS These include schizoaffective disorder (where symptoms of chronic psychosis are interspersed with major mood episodes) and delusional disorders (in which a fixed, unshakable delusional belief is held in the absence of the other stigmata of schizophrenia). Pts with somatic delusions can be especially difficult to diagnose; they may become violent towards the physician if they feel misunderstood or thwarted and they almost always resist referral to a psychiatrist.
Characterized by severe, persistent anxiety or sense of dread in the absence of psychosis or a severe change in mood. Most prevalent psychiatric illness seen in the community; present in 15–20% of medical clinic patients.
PANIC DISORDER Occurs in 1–2% of the population; female:male ratio of 2:1. Familial aggregation may occur. Onset in second or third decade. Initial presentation is almost always to a nonpsychiatric physician, frequently in the ER, as a possible heart attack or serious respiratory problem. The disorder is often initially unrecognized or misdiagnosed. Prompt diagnosis and treatment can greatly reduce morbidity.
Clinical Features Characterized by panic attacks, which are sudden, unexpected, overwhelming paroxysms of terror and apprehension with multiple associated somatic symptoms. Attacks usually last 10–20 min, then slowly resolve spontaneously. Diagnostic criteria for panic disorder require four or more panic attacks within 4 weeks occurring in nonthreatening or nonexertional settings, and attacks must be accompanied by at least four of the following: dyspnea, palpitations, chest pain or discomfort, choking/smothering feelings, dizziness/vertigo/unsteady feelings, feelings of unreality, paresthesia, hot and cold flashes, sweating, faintness, trembling, and fear of dying, going crazy, or doing something uncontrolled during an attack. Panic disorder is often associated with a concomitant major depression.
When the disorder goes unrecognized and untreated, pts often experience significant morbidity: they become afraid of leaving home and may develop anticipatory anxiety, agoraphobia, and other spreading phobias; many turn to self-medication with alcohol or benzodiazepines.
Panic disorder must be differentiated from cardiovascular and respiratory disorders. Conditions that may mimic or worsen panic attacks include hyper- and hypothyroidism, pheochromocytoma, complex partial seizures, hypoglycemia, drug ingestions (amphetamines, cocaine, caffeine, sympathomimetic nasal decongestants), and drug withdrawal (alcohol, barbiturates, opiates, minor tranquilizers).
Cognitive-behavioral psychotherapy (identifying and aborting panic attacks through relaxation and breathing techniques)—either alone or combined with medication—is highly effective. Selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, and monoamine oxidase inhibitors all treat the disorder and prevent spontaneous attacks. Clonazepam, lorazepam, or other benzodiazepines may be used in the short term while waiting for antidepressants to take effect (2–3 weeks).
GENERALIZED ANXIETY DISORDER (GAD) Characterized by persistent, chronic anxiety but without the specific symptoms of phobic, panic, or obsessive-compulsive disorders; occurs in 2–3% of the population.
Clinical Features Pts experience persistent motor hyperactivity (shakiness, trembling, restlessness, easy startle), autonomic hyperactivity, apprehensive expectation (anxiety, fear, rumination, anticipation of misfortune, etc.), and vigilance (distractability, poor concentration, insomnia, impatience, and irritability). These symptoms are chronic and pervasive, rather than situational. Secondary depression is common.
Benzodiazepines are the initial agents of choice when generalized anxiety is severe and acute enough to warrant drug therapy. A trial of an SSRI antidepressant should then be started as many pts will experience significant relief with this class of medications. Physicians must be alert to psychological and physical dependence on benzodiazepines. A subgroup of pts respond to buspirone, a nonbenzodiazepine anxiolytic. Psychotherapy and relaxation training can be useful.
OBSESSIVE-COMPULSIVE DISORDER (OCD) A severe disorder present in 4–6% of the population and characterized by recurrent obsessions (persistent intrusive thoughts) and compulsions (repetitive behaviors) that the pt experiences as involuntary, senseless, or repugnant. Pts are often ashamed of their symptoms and only seek help after they have become debilitated.
Clinical Features Common obsessions include thoughts of violence (such as killing a loved one), obsessive slowness for fear of making a mistake, fears of germs or contamination, and excessive doubt or uncertainty. Examples of compulsions include repeated checking to be assured that something was done properly, hand washing, extreme neatness and ordering behavior, and counting rituals, such as numbering one’s steps while walking.
Onset is usually in adolescence, with 65% of cases manifest before age 25. It is more common in males and in first-born children. In families of OCD patients, an increased incidence of both OCD and Tourette’s syndrome is found. The course of OCD is usually episodic with periods of incomplete remission. Pts with severe disease may become completely housebound. Major depression, substance abuse, and social impairment are common.
Clomipramine and the SSRIs are highly effective. A combination of drug therapy and CBT is most effective for the majority of pts. Education and referral to a national support organization is also useful.
POSTTRAUMATIC STRESS DISORDER (PTSD) Occurs in a subgroup of individuals exposed to a severe life-threatening trauma. Predisposing factors include a prior history of traumatization and/or a diathesis toward anxiety responses. Early psychological intervention following a traumatic event may reduce the risk for chronic PTSD.
Clinical Features Three core sets of symptoms: (1) reexperiencing, where the pt unwillingly reexperiences the trauma through recurrent intrusive recollections, recurrent dreams, or by suddenly feeling as if the traumatic event is recurring; (2) avoidance and numbing, where the pt experiences reduced responsiveness to, and involvement with, the external world, a sense of a foreshortened future, and avoidance of activities that arouse recollection of the traumatic event; (3) arousal, characterized by hypervigilance, hyperalertness, an exaggerated startle response, sleep disturbance, guilt about having survived when others have not or about behavior required for survival, memory impairment or trouble concentrating, and intensification of symptoms by exposure to events that symbolize or resemble the traumatic event. Comorbid substance abuse and other mood and anxiety disorders are common. This disorder is extremely debilitating, particularly as it becomes chronic and affects psychosocial functioning. Most pts require referral to a psychiatrist for ongoing care.
Medications used with varying success include a combination of an SSRI and trazodone, 50–200 mg qhs for sleep; tricyclic antidepressants; and mood stabilizers. Group psychotherapy (with other trauma survivors), alone or with individual psychotherapy, is useful.
PHOBIC DISORDERS Clinical Features Recurring, irrational fears of specific objects, activities, or situations, with subsequent avoidance behavior of the phobic stimulus. Diagnosis is made only when the avoidance behavior is a significant source of distress or interferes with social or occupational functioning.
1. Agoraphobia: Fear of being in public places. May occur in absence of panic disorder, but is almost invariably preceded by that condition.
2. Social phobia: Persistent irrational fear of, and need to avoid, any situation where there is risk of scrutiny by others, with potential for embarassment or humiliation. Common examples include excessive fear of public speaking and excessive fear of social engagements.
3. Simple phobias: Persistent irrational fears and avoidance of specific objects. Common examples include fear of heights (acrophobia), closed spaces (claustrophobia), and animals.
Agoraphobia is treated as for panic disorder. SSRIs are very helpful in treating social phobias. Social and simple phobias respond well to CBT and relaxation techniques and to systematic desensitization and exposure treatment.
SOMATOFORM DISORDERS Clinical Features Pts with multiple somatic complaints that cannot be explained by a known medical condition or by the effects of substances; seen commonly in primary care practice (prevalence of 5%). In somatization disorder, the pt presents with multiple physical complaints referable to different organ systems. Onset is before age 30, and the disorder is persistent; pts with somatization disorder can be impulsive and demanding. In conversion disorder, the symptoms involve voluntary motor or sensory function. In hypochondriasis, the pt believes there is a serious medical illness, despite reassurance and appropriate medical evaluation. As with somatization disorder, these pts have a history of poor relationships with physicians due to their sense that they have not received adequate evaluation. Hypochondriasis can be disabling and show a waxing and waning course. In factitious illnesses, the pt consciously and voluntarily produces physical symptoms; the sick role is gratifying. Munchausen’s syndrome refers to individuals with dramatic, chronic, or severe factitious illness. A variety of signs, symptoms, and diseases have been simulated in factitious illnesses; most common are chronic diarrhea, fever of unknown origin, intestinal bleeding, hematuria, seizures, hypoglycemia. In malingering, the fabrication of illness derives from a desire for an external gain (narcotics, disability).
Pts with somatoform disorders are usually subjected to multiple diagnostic tests and exploratory surgeries in an attempt to find their “real” illness. This approach is doomed to failure. Successful treatment is achieved through behavior modification, in which access to the physician is adjusted to provide a consistent, sustained, and predictable level of support that is not contingent on the pt’s level of presenting symptoms or distress. Visits are brief, supportive, and structured and are not associated with a need for diagnostic or treatment action. Pts often benefit from antidepressant treatment. Consultation with a psychiatrist is essential.
PERSONALITY DISORDERS (AXIS II DIAGNOSES)
Defined as an inappropriate, stereotyped, maladaptive use of a certain set of psychological characteristics; affects 5–15% of the general population. The pattern of behavior is enduring and affects the person’s relationships and ability to function satisfactorily in life.
Comorbid Axis I diagnosis is common, as is a psychoactive substance use disorder. In medical and surgical settings, pts with personality disorders often become engaged in hostile, manipulative, or unproductive relationships with their physicians. Long-term psychotherapy is beneficial for pts who are motivated to change. Antidepressants and antipsychotic medications can be helpful, particularly for episodes of decompensation, but should be prescribed in consultation with a psychiatrist as misdiagnosis is common.
DSM-IV describes three major categories of personality disorders; pts usually present with a combination of features.
Cluster A Personality Disorders
Affected pts are often characterized as “wild” or “mad.” The paranoid personality is suspicious, hypersensitive, guarded, hostile, and can occasionally become threatening or dangerous. The schizoid personality is interpersonally isolated, cold, and indifferent, while the schizotypal personality is eccentric and superstitious, with magical thinking and unusual beliefs resembling schizophrenia.
Cluster B Personality Disorders
Patients with these disorders are often “wild” or “bad.” The borderline personality is impulsive and manipulative, with unpredictable and fluctuating intense moods and unstable relationships, a fear of abandonment, and occasional rageful micropsychotic episodes. The histrionic pt is dramatic, engaging, seductive, and attention-seeking. The narcissistic pt is self-centered and has an inflated sense of self-importance combined with a tendency to devalue or demean others, while pts with antisocial personality disorder use other people to achieve their own ends and engage in exploitative and manipulative behavior with no sense of remorse. Some aspects of the Cluster B personality disorders appear related to mood disorders.
Cluster C Personality Disorders
Patients with these disorders are often “whiny” or “sad.” The dependent pt fears separation, tries to engage others to assume responsibility, and often has a help- rejecting style. Pts with compulsive personality disorder are meticulous and perfectionistic but also inflexible and indecisive, while those who are passive- aggressive request help, appear compliant on the surface, but undo or resist all efforts aimed at change. Avoidant pts are anxious about social contact and have difficulty assuming responsibility for their isolation. The personality disorders share some features with the anxiety disorders
* Diagnostic and Statistical Manual, Fourth Edition, American Psychiatric Association
For a more detailed discussion, see Reus VI: Mental Disorders, Chap. 385, p. 2542, in HPIM-15.