A Short Course in Psychiatry
James Morrison, M. D.
Professor of Clinical Psychiatry
Oregon Health & Science University
January 2009
Contents
Preface
iii
Chapter 1
Interviewing Psychiatric Patients
1
Chapter 2
Making a Psychiatric Diagnosis
29
Chapter 3
Depression
33
Chapter 4
Mania and Mood Swings
54
Chapter 5
Psychosis and Schizophrenia
69
Chapter 6
Anxiety and Panic
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 index—sorry about that, but time got away from
me), I’d 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 you’ll find are my own
responsibility.
This is a work in progress; I’d greatly appreciate it if you’d write to me about this material—
what do you find useful, what’s confusing, how can we improve it for readers in years to come?
James Morrison, M. D.
Portland, Oregon
January, 2009
morrjame@ohsu.edu
iii
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, “I’m 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 you’ll 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 patient—this gives you room to change the distance between you, as indicated by
the patient’s 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 you’d 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 I’ve quoted are open-ended. That means, they can’t be answered
“yes” or “no” and you haven’t 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
don’t limited the scope of your information.
•
They serve as bait when you are fishing for the sorts of problem you’ll need to explore.
•
Because the patient does most of the talking, they allow you to assess your patient’s
thought and speech patterns.
•
Patients who are encouraged to talk freely tend to like the person doing the encouraging.
1
Interviewing
2
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 you’ll 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 you’d 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,
you’ll gather details about each area your patient mentions. After moments to minutes of letting
your patient talk freely, you’ll sense that you’ve obtained a broad outline of what’s uppermost in
your patient’s mind. Then, after asking, “Are there any other important problems we haven’t
mentioned?” move on to explore in depth the problem areas you’ve identified.
Rapport
Before we move on, let’s consider the relationship you’re trying to establish. Rapport, the sense
of mutual trust and understanding that helps people work together, is the second of two basic
Interviewing
3
goals you hope to score during your initial interview (clinical information is the first). Most
patients will expect to like you, but don’t coast on this expectation; take steps to build good will:
•
Watch your patient’s demeanor. If it’s depressed, you will naturally feel like moving a
little closer for support. If angry or hostile (or euphoric), you’ll want to back off to give
each of you more personal space. (Here’s 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 you’ve 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: “I’ve 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 patient’s 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 won’t 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 patient’s feelings, rather than words or behavior, you might
avert your own negative feelings. For example:
PATIENT: I don’t care about women. I’d like to see every one of them burn in hell.
INTERVIEWER: Sounds like you’re 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:
“You’ve really given me a good overview of your problem. I think we can move on to
some other information, now.”
“That’s about the best ‘serial sevens’ I’ve 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
4
Boundaries
The doctor–patient 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 patient’s title and last
name—Miss, 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 “elderspeak”—“Sweetie,” “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 patient’s interests and needs, not on your own. It’s 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 I’d scrupulously avoid extending it
to politics or religion—even 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 don’t have to answer personal questions, but you may want to do so; it
depends on the patient’s reason for asking— it may be simple curiosity or a desire to obtain
reassurance about the clinician’s 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 didn’t grow up here, but I got most of my training here. I’ve
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 you’ll 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 wouldn’t give a direct answer about
age, which really isn’t any of the patient’s business; instead, I’d probably thank the patient for
5
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 let’s 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 two—“Yes” or “Mmhmm”—can 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 patient’s own last word to request more in the same line of thought.
PATIENT: …and during the last few weeks, I’ve thought a lot about death.
INTERVIEWER: Death?
PATIENT: Well, Dad died, and I felt so frightened. I’ve got so much living to do…
•
Reach back to a phrase or idea that wasn’t the patient’s last-spoken thought: “Earlier, you
said that you’d 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 what’s 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 patient’s 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 wouldn’t worry about that” or “I’m sure it will all work out just fine.”
(Many patients will grumble that, in your place, they wouldn’t worry, either.) And because you
obviously can’t peer into the future, your words will seem hollow and reduce your credibility.
You can reassure with praise, but only offer it when it’s deserved: “I think you handled your boss
with tact and sensitivity. I can see why you are valued in your company.”
6
Interviewing
Gathering the Database
History of the present illness
Once you’ve identified some of the major problem areas you need to explore, start exploring!
This means learning all you can about the current episode of illness—how 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 patient’s 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 patient’s
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
occurs—terminal (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 hasn’t 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 patient’s 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 patient’s 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
7
Stressors
Some disorders seem to begin spontaneously, but you’ll often identify an event that may have
caused, precipitated, or worsened your patient’s 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 haven’t 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 it’s obvious—acute
intoxication or a suicide attempt—but 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.
You’ll 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
You’ll 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 doctor’s 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
they’ll 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 tears—each 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.”
Interviewing
8
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 dying—“gestures” such as a lightly scratched wrist or swallowing 4 or 5 aspirin.
A psychologically serious attempt is one where death seems clearly intended—the patient
took pains to avoid discovery or greets survival with regret: “I’m sorry it didn’t work” or “I’ll 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, “I’m glad I didn’t 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, you’ll 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, you’ll 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
patients—being 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 isn’t.
4. Watch for indicators of potential violence in the patient’s 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 patient’s 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.) Don’t be put off by someone who says, “I don’t touch alcohol.” That could mean, “I
haven’t 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, you’ll need to explore the following areas:
9
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?” “What’s 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, don’t realize that misinformation
can have serious consequences.) That’s why I might say, “I understand that you hesitate to
confide in me. Let’s play it this way: If you feel you can’t tell me the truth, just say, ‘Let’s skip
that for now,’ and we’ll move on. That way, I won’t 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 patient’s 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 ago—I 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 can’t breathe. It’s awfully scary.
INTERVIEWER: How often have these attacks occurred? [Closed-ended]
PATIENT: I’m not sure—it’s been getting more frequent.
Interviewing
10
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]
PATIENT: I’m 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, I’ll 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 patient’s street terms for sexual
acts and body functions.
•
Don’t phrase questions in the negative—it telegraphs the expected answer. “You haven’t
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 doesn’t 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 don’t
really know the patient well.
But when the stakes are high—let’s say your diagnosis turns on this fact—you 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. Here’s another way to soften the question: “When you told me what
happened to your wife, I felt sad—but you are smiling. What else is there to this story?”
Of course, during an interview session, you should play the confrontation card sparingly.
Interviewing
11
Interviewing about feelings
Studies show that beginning interviewers often neglect to ask about feelings—a serious omission
in a mental health interview. Eliciting quality information about feelings is usually pretty easy—
just ask, using techniques we’ve 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 husband’s affair make you feel?” or “What was your state of mind
when you found out you’d 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 you’d considered leaving your job—tell me more about that.
PATIENT: I’ve had a really tough time at work, what with downsizing. My boss has put me
under an awful lot of stress. At times I’ve felt that I can’t 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 I’ve dreamed about…
Although most patients will give you information about any emotional state you are
interested in, some find it hard to talk about feelings—perhaps their relatives hid their emotions
or their culture discouraged behavior that isn’t “macho.” Some just don’t 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 who’s 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 anxiety—can 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 don’t 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 wouldn’t even let me—
INTERVIEWER (interrupting): Did you and she have any kids?
PATIENT: Two, and they’re 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, we’ll 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; it’s her mother who turned her against me.”
Devaluation. “She’s actually pretty dumb; I can’t 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. “I’ll write a book, earn a potful of money, and she’ll beg me to take her back.”
Intellectualization. “I agree with Tennyson, it’s ‘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 girlfriend’s CD collection.]
Splitting. “Women can be wonderful or horrible; she’s 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 wouldn’t 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, I’ll plan better to protect my feelings.”
Humor. “I called her an angel; she said I was a rat. Maybe we were both wrong.”
Sublimation. “I’ll use this time to study hard and complete my education.”
Suppression. “I’ll put this on the back burner; I’ve 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) you’ll want a general picture of your patient’s 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
You’ll 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, you’ll
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 patient’s social support network—the number and quality of relationships with family and
friends. Support issues can help assess your patient’s 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
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Interviewing
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 patient’s 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. You’ll 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: “I’m trying to find out how your sexual functioning is usually, and how it’s been
affected by [the presenting problem].” You’ll also want to learn something about early sexual
experiences (age and nature, patient’s 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.
Don’t 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 you’ll 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 patient’s 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 patient’s 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 anyone—any type of person—you can’t 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 anyway—that’s 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 patient’s 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 you’re
after, you’ll need to be explicit. I usually start with a rather long speech like this one:
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Interviewing
“I’d 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 won’t 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 don’t
accept a diagnosis of schizophrenia, just because that’s what family mythology has passed along
as the reason for Grandpa Jim’s 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? You’ll need to encourage brevity without impairing
rapport.
•
State your need to move on: “I’d like to hear about that later, if there’s time. Now, let’s
focus on…” or “Let me interrupt here to pursue something else that’s important.”
•
Nod or smile approval when you get the sort of brief answer you’d 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…” “Let’s stick with the main topic for now…”
•
By this time, you’ll be using more closed-ended questions—those that can be answered
“Yes” or “No” or with a specific piece of information such as a date or name—but don’t
completely abandon open-ended questions. They’re 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 patient’s own idea or words:
PATIENT: …my wife’s 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 factor—place, time, relationship—can 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 you’re intentionally
changing direction: “I’d like to change gears, now, and ask you about…”
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Demonstrate concern for the patient’s feelings, especially with highly charged questions.
•
A sympathetic facial expression or tone of voice can soften any question.
•
With “I realize your husband’s death makes it hard to talk about him,” you acknowledge
your patient’s 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 who’s had drug problems?” By
asking how others would react or feel in a similar circumstance, you can reduce your
patient’s 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 didn’t.
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. You’ll 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 don’t 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:
• Don’t be drawn into the patient’s anger or other agenda issues. Remember that the issue
isn’t you, it’s 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 you’d had the desire to die?
•
Give the patient a degree of control with something like, “Just tell me what you’d 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 it’s hard to deal with some of this material. It’s hard, and it’s
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 first—just a nod of the head will
do.
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•
Only as a last resort should you delay the discussion; you want your patient to develop
the habit of responding to your requests.
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 didn’t happen: “Nobody died, did they?”
•
Induce the patient to brag: “Has there been any behavior for which you could have been
arrested, but weren’t?”
Mental Status Exam—Observational 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, you’ll have to ask questions.
General appearance and behavior
Besides ethnicity, gender, and apparent age, you’ll 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 ideas—the 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 mannerisms—the 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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Interviewing
the room, as if listening to voices or noticing something you cannot see may be experiencing a
psychosis. Notice your patient’s 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 patient’s 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 patient’s 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 we’ll 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 one’s 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 Parkinson’s disease and other neurological illnesses.
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Appropriateness
How well does your patient’s 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 don’t 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 without—and then with—psychosis). You might also
consider whether the mood is fleeting or prolonged, or somewhere in between.
Finally, there’s 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 patient’s 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 can’t agree on where to have breakfast, let alone these definitions. I’ve
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 haven’t yet had
a run of free speech to evaluate the quality of your patient’s thinking, better ask: “I think I could
get a better feeling for what’s 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 rules—but
not by logic you can understand. “She tells me something in one morning and out the other.”
“I’ve 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. That’s 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:
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INTERVIEWER: Can you tell me about your relationship with your mother?
PATIENT: My golf balls got pink dimples.
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 don’t 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 doesn’t 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. She’s 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 wasn’t the. . . best hatred. . . lifetime .” Sometimes termed word salad.
•
Neologisms. In the absence of artistic intent (such as Lewis Carroll’s 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 patient’s manner of speaking. Because speech
patterns can be shaped by cultural or geographic influences, by neurological disorders, and the
patient’s 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 patient’s
answer). Both of these are typically found in mania patients, who may say that their words can’t
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 speaker’s
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 Exam—Cognitive 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. “That’s terrific, the best calculations anyone’s
done for me this week.”
•
Watch for any distress your questions might cause and respond appropriately. “Yeah,
mentally subtracting sevens can be hard. Let’s give it a rest and try presidents, instead.”
Do the formal part of the MSE early in your acquaintance—you need the data base
information, and if you put it off, you’re likely either to forget it or ignore it.
Content of thought
This means, the focus of an individual’s thought at any given time. For most people, you’ll note
that the content of thought is largely the concern that brought them for evaluation; for most
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outpatients it will seem pretty normal. However, psychiatric patients can have a variety of
thoughts that aren’t at all normal, some of which you need to ask about.
Delusions
A delusion is a fixed, false belief not explained by the patient’s 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: I’d 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 “I’m just not sure,” the
idea isn’t a delusion. It must also pass the cultural criterion: you wouldn’t 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 won’t usually dislodge them. Examples include the superiority of one’s own gender, race,
or religion. Sometimes, as with racial hatred, they interfere with the individual’s 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 patient’s 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 they’re 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 patient’s spouse has been unfaithful—classically encountered in alcoholic
paranoia, but also in paranoid schizophrenia and paranoid disorder.
Persecution. One of the more common types of delusion, the patient’s 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.
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Thought broadcasting. The patient’s thoughts are somehow transmitted, perhaps by radio
waves. Similar to delusions of mind-reading. Schizophrenia.
Thought control. Feelings, ideas, or thoughts are put into (thought insertion) or withdrawn
from the patient’s 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 don’t normally like “why” questions, which often yield little
new information. Here, a “why” question might elicit elaboration of the delusion.)
Is the delusion mood-congruent—does the content fit the patient’s mood? A severely
depressed man’s 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 doesn’t have true auditory
hallucinations. You can ask, “Is the voice as clear as mine?” Again, discount “no” answers. In
audible thoughts, the patient’s 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 patient’s behavior (these have been called “first rank”
symptoms of schizophrenia)? Does the patient recognize the speaker? Where is it coming
from?—The patient’s 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 injury—or 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 frightening—as one of my
patients discovered upon looking into a mirror and noting that he had the face of a camel.)
You’ll 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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24
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 paralyzed—couldn’t 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 one’s 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 you’re 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 isn’t 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 patient’s 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 patient’s 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 couldn’t 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 anxiety—intense, 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 compulsions—such as
rituals or routines you feel you must perform over and over, even though you try to resist?”
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Suicide and violence (again)
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 patient’s ability to absorb,
process, and communicate information. I never describe these routine tasks as “silly”—that 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: “It’s 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 patient’s 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 person’s 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
You’ll 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
doesn’t 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) isn’t lying, because these people seem to believe what they
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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.”
Screen for aphasias by asking the patient to name the parts of a ball point pen: point, clip, barrel.
•
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.
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 you’ve 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 don’t think I’ve ever read the reason why. The other points out that any warning
invites cognitive rehearsal, which could mean that a patient benefits from practice—and 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 cosmic—perhaps either method’s 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 patient’s 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 patient’s 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
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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 Alzheimer’s will lose even long-retained information.
You’ll 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
ascertain—the natural answer to “Have you ever suffered from amnesia?” is “I don’t 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 (“What’s the last thing you can recall just before the period of
amnesia; what’s the first thing you can recall afterwards?”). You could also ask, “Have friends or
relatives tried to help you reconstruct what happened?” Don’t assume that a memory hole means
something bad happened—clinicians have come to grief persuading patients that amnesia
implies assault or molestation, the notorious false memory syndrome.
Cultural information
These tasks mainly assess the patient’s remote memory and general intelligence, so some texts
don’t 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, it’s fair to
try to jog your patient’s memory.
“Let’s see, did you leave out anyone?” or, “He’s 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 patient’s 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 shouldn’t
throw stones?” “Can you tell me what this means—A 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 patient’s ideas about what is wrong. It may be evident, but you can ask:
“Do you think there is something wrong with you?”
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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?”
Insight may be full, partial, or nil—a 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 strengths—what they think they are good at—can be
important for recommending treatment and estimating prognosis. Evaluate your patient’s 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
I’m 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. I’m 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, you’ll 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
you’ll 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-language—such 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
précised.
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. We’ll briefly explore two aspects of this paradigm shift.
The DSM-IV system of diagnosis
In the 1970s, the US–UK 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 don’t count
symptoms—for 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. That’s 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 wouldn’t 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
29
30
Diagnosis
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 disorders—all except
*
the two listed on Axis II.
Axis II
Personality disorders and mental retardation. Listing these on a separate axis helps ensure
that they won’t be overlooked. Each requires criteria.*
Axis III Physical conditions and disorders. Some of them may have a bearing on our patient’s
mental condition or treatment.*
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 patient’s progress across time.†
90–100 Functions well in a wide range of activities; no symptoms
81–90 Few if any symptoms; good functioning in all areas
71–80 Any symptoms are transient and expected reactions to stressors; slight, if any,
job, social impairment
61–70 Some mild symptoms or some problems in functioning
51–60 Moderate symptoms or moderate problems in functioning
41–50 Serious symptoms or serious impairment in functioning
31–40 Some impairment of communications or reality testing or major impairment
in several areas (work, judgment, thinking, family relations)
21–30 Behavior shaped by delusions/hallucinations or seriously impaired judgment
or communication
11–20 Some danger of harm to self or others or failure to maintain minimal personal
hygiene or grossly impaired communications
1–10 Persistent danger of severe harm to self or others or persistent failure to
maintain personal hygiene or serious suicidal act
0 Inadequate information
*
You’ll find numbers (and a few letters) tacked onto the diagnoses associated with Axes I–III. These are coding
devices for the folks in the record room; we don’t need to worry about them here.
†
The DSM-IV manual includes numerous GAF examples.
31
Diagnosis
Here’s how we might use the 5-axis structure to describe a patient. Let’s 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,
here’s how we’d report our evaluation:
Axis I
Paranoid schizophrenia, chronic
Alcohol dependence
Axis II
Schizoid personality disorder
Axis III
None
Axis IV
Currently in jail
No network of support
Axis V
GAF = 25 (current)
However, just knowing the skeleton, even if you can flesh it out with diagnostic criteria, isn’t
nearly enough. On a given day, you could conceivably find enough symptoms in most patients to
suggest a variety of diagnoses that wouldn’t 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, that’s 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 we’ve 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 consider—and reconsider—all 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.
32
Diagnosis
•
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 risk—of 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 you’d
prefer for yourself or a family member—if 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 difference—disorders like AIDS-related dementia, Alzheimer’s, 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 manual—DSM-IV-TR—provides 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 Morrison’s DSM-IV
Made Easy in the OHSU library.
Peculiarly enough, the diagnostic process is something that most psychiatric texts don’t pay
much attention to. Diagnosis Made Easier comprises what I’ve learned in 40 years about sifting
information to make a psychiatric diagnosis. There’s a copy in the OHSU library.
Chapter 3
Depression
“It was the insomnia that got my attention,” Suzanne told her PCP. “I’ve 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 haven’t got much
energy for anything; I just sit and stare out the window. I feel like I’ve 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. “I’ve never felt depressed and worthless like this before,” she said, fighting back
tears. “I don’t even want to talk on the phone with my friends, let alone see them.” Though
her weight hadn’t 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
didn’t drive). However, being with people didn’t help her shake off the constant fatigue.
She said she’d never before felt so miserable and often found herself crying “over
nothing.”
For about 5 months, she said, the stress of her job—she worked at home for a dotcom
marketing firm—had been getting to her, so she’d cut back to part time. “And I’ve been so
irritable with Jack, I’m lucky he didn’t just leave me.” Instead, he had urged her to seek
help, had even made the call for her. “I didn’t 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 won’t have them all, 9 core
33
Depression
34
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.
Depressed mood. The patient feels sad or some equivalent—mournful, blue, despondent,
anguished, or simply “down”—or 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 Suzanne’s
case, it was cooking, but hobbies and interests such as reading, watching TV—even having
sex—typically 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, it’s 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, you’ll 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 person’s mood.) Some patients feel
35
Depression
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 episode”—and they’ll cause only minimal
inconvenience. These patients will probably still sleep and eat pretty well, and they’ll continue
with work and family life.
Moderate. As more symptoms accumulate, they begin to dominate the person’s life. Insomnia
yields daytime fatigue; failing appetite causes weight loss; guilt feelings crowd out other
thoughts. Those who still go to work don’t 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 isn’t 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 episodes—major depressive, manic, hypomanic, or mixed—is present (we’ll
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.
36
Depression
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 they’ll agree
that it’s a distinct change from normal, not just a worsening of how they usually feel. A few
people don’t 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 physical—a severe headache or
abdominal pain—which 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
wasn’t 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 patient’s 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 we’ve defined the
major depressive episode (see Table 1).
Major Depressive Disorder
And now to the diagnosis of Suzanne’s actual mood disorder. Suzanne’s 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 hadn’t been depressed long enough for a diagnosis of
dysthymia; and that she’d never had an episode of mania or hypomania. She also didn’t 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 don’t
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
months—perhaps nine, on average—and resolve with a complete return to previous level of
functioning. Patients who don’t recover completely follow one of two general patterns: some
Depression
37
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 10–25%; men
come in at just about half that. (In children, boys and girls are about equally affected; and we just
don’t 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
Depression
38
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 terms—feeling 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 theories—for 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 needed—one 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 phases—an 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 patient’s 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 choice—these have fewer side effects than most other TCAs. As with most drugs,
Depression
39
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 don’t 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 they’ll 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 doesn’t 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.
Depression
40
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 stool—the biopsychosocial approach to healthcare—remember 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, you’ll need to:
• Obtain any additional information that was overlooked on the first interview. There’s
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 appeared—enough 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 well—and 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 medication—this 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 change—for the better—in
how they feel (“It was like someone threw a switch”). From that moment on, they “knew” that
Depression
41
they were no longer ill. With this experience, they can stop treatment. However, for most
patients, after 9 months or so you’ll 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, they’ll
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. We’ll discuss them later (page 45).
The physician’s approach to the patient
What not to say
There are dozens of things a depressed person doesn’t 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 don’t work well:
“Nobody promised life would be fair.”
“If you’d 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, happiness—it’s all choices you make.”
“I know just how you feel—I 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.
“I’ve known dozens of people who’ve 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 you’ll get over this and be well. And I believe your doctor.”
“I can’t imagine feeling the way you do, but I can feel how much you are hurting.”
“Call me anytime—I’ll respond.”
“It’s OK to [cry] [be depressed] [feel angry], I’ll still care.”
“I’ll see this through with you.”
“You are so important in my life.”
“I know you can’t help the way you feel, and it won’t change the way I feel about you.”
“When we get through this, we’ll still be together.”
“I love you.”
42
Depression
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 son’s divorce
Alice began to blame herself. She brooded that she had spent too much time worrying
about herself and not enough time making her son’s 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 “couldn’t care less” about her job as a florist’s assistant. “I’d plop the flowers into a
glass of water, and if they didn’t 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
she’d 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 don’t feel much better, but in
Marge’s 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 aren’t 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 Alice’s depressive symptoms were alarming: increasing feelings of guilt (she
recognized that these were exaggerated, so she wasn’t psychotic) and thoughts about
driving off a cliff. Although she still went to work, she didn’t function well there. These
symptoms spelled a moderately severe depression, so she was offered medication,
psychotherapy and social supports—the classic biopsychosocial approach to psychiatric
management.
43
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.
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.
Brian’s wife, Joyce, worked quickly when she found him cleaning the shotgun he hadn’t
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, Brian’s mood had darkened
and the chores on his almond farm seemed a burden. Mornings were worst—”Another
damn day to get through,” he would mutter on his way outdoors. Joyce couldn’t 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 there’s my paycheck. But Brian insists we’re povertystricken, that we’ll have to sell out.”
As time passed, Brian spoke less and less. When he did talk, he apologized for all the
pain he had caused—Joyce 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 he’d 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. He’d ask to have
his blood pressure taken several times an hour. “I pointed out that he’d 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.
44
Depression
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. Brian’s 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 Brian’s 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 unit—anyone
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 there’s a plan and a means ready to hand. If hospitalization
isn’t 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 episode—that’s
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.
45
Depression
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 2–3 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 person’s life was badly disrupted—divorce, 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 3–4 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 2–3 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,
you’ll 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 patient’s consent, fully inform family and close friends about the mood disorder and
the symptoms of recurrence to watch for. Some patients don’t 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 don’t 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 (“I’ve always been
Depression
46
depressed”). They can go for years without realizing that persistent low mood isn’t 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” dysthymia—unless it is recognized and
treated.
Despite his years-long marriage to Carol, Ira admitted that he had always felt lonely and
isolated. “I’ve never been self-confident, but she sure hasn’t helped matters any. According
to her, I’ve never done anything right with the kids—couldn’t 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. “I’ve never been worse, but I’ve
never been much better, either. It didn’t 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 won’t
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 person’s character structure,
recognizing it may be a problem—Ira’s symptoms seemed normal to him. Ira’s 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 isn’t dramatic. Perhaps that explains why it often goes unrecognized and undertreated, despite affecting about 3% of adults.
Depression
47
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 Sjögren’s, where it frequently begins before the typical
physical symptoms of the syndrome. Some verge on the exotic—tick-borne Lyme disease, for
example. It is unusual for these conditions to cause depression, and that’s exactly what makes
them dangerous—if they routinely produced depression, we’d consider them first with every
patient we see. Unhappily, often it’s only when antidepressants and psychotherapy don’t 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 don’t need specific
treatment, but they do require special care with diagnosis. That’s why physicians must ask
questions to dredge up all the facts about their patient’s 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. Don’t confuse this
depressive syndrome with the milder—and far more common—“baby 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 outcome—a
promotion lost or a romance gone awry. As the months drag by, someone who has lost a job and
can’t find another might feel increasingly dejected; it’s 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. Here’s the sort of situation that’s ready-made for the
term Adjustment Disorder with Depressive Features—in effect, a depression that’s sort of
normal.
Adjustment disorders (including subtypes with various features—depression, anxiety, mixed
anxiety and depression, disturbed conduct, mixed disturbance of emotions and conduct, and
unspecified) are diagnosed so commonly they constituted up to 10–30% 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 isn’t always clear-cut. Although
we might think that the sole cause of such a depression was job loss, we could discover that the
48
Depression
patient’s 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 can’t 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 hasn’t been
especially well studied for which there isn’t any specific treatment—other than allowing time to
pass. It is a type of depression (or anxiety disorder) that should be placed pretty close to the
bottom of anyone’s 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 2–3 months, most clinicians would then
treat for major depression, perhaps emphasizing a specific psychotherapy such as CBT.
Treatment-resistant Depression
“Treatment-resistant” doesn’t mean a distinct type of depression; it’s 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.
“It’s stopped working. I’m back to the way I used to feel, though I’m still taking the
same dose—10 mg.”
Now, Jon’s 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 he’s been
fine ever since.
Jon was getting the right medicine but at the wrong dose—his 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.
Jon’s 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
49
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 it’s 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.
Drugs and other physical methods of treatment are just plain wrong for some depressions.
Earl’s “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 isn’t helping,
perhaps weekly sessions will work better.
Has treatment been given long enough? Antidepressants can require 6–8 weeks for full
effect, but 2–3 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 don’t respond
well to one treatment may improve with another. Although professional opinions vary, if a
patient hasn’t 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 isn’t
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 MAOI—they 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 depressed—they’ve experienced
so many losses—and 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.
50
Depression
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 he’d
worked in his brother’s machine shop, but now he mostly just sat at home. A couple of
years earlier, his wife had died. They’d 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 frame—he 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 wouldn’t 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, Jay’s 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 haven’t 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
Depression
51
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 2–3
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 don’t 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.
52
Depression
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 don’t 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 risk—especially 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 he’d always felt unsure of himself, rather lowspirited, to tell the truth. “It’s normal for me—like 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. “It’s just hopeless,” he complained to Francine, his girl
friend. “I’m in a terrible rut.”
By the time 5 years had passed and he’d 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 didn’t
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 Carl’s symptoms of a major depressive episode. [p 33]
Outline your suggested treatment approach for Carl. [p 38]
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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
Further Learning
A lot of memoirs discuss depressive disease and its consequences. Besides those I’ve 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 O’Malley’s 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 plié, she
alighted in a chair and at once began to speak.
“I’m 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. “I’ve 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 don’t 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. “I’ve got to have one for work,” she said, “and
I’m 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
54
Mania
55
on a psychiatry ward. Hi, psych ward! [Looking around the room] Any other Wards here?
My dad’s name was Edward. Edward the Confessor. Me, I confess, I’m only Princess Di.”
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. We’ll cover them later in this chapter,
but first, let’s 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 Brie’s 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 “high”—excited, 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 isn’t too high, we feel good and want to laugh.
However, some mania patients aren’t 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 hostility—especially 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 up—they 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 don’t 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 another—a form of thought disorder called flight of ideas.
Brie’s last speech provides an example.
Distractibility. Small diversions—noises in the hallway, a fly on a window sill, a cola can
under a table—can 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 don’t describe insomnia as a problem—why 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. Brie’s comment
about her “great body” suggests inordinate feelings of self-worth.
Faulty judgment. Brie impulsively bought pens she didn’t need and disrobed in public; other
mania patients spend thousands they cannot afford, sign contracts they can’t fulfill, have sexual
indiscretions. Their actions—whether gambling, drinking, using drugs, or violating professional
ethics, such as having sex with patients or spending money entrusted to them by clients—can
endanger themselves and those around them.
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Mania
Typically, patients with mania don’t recognize that they are ill or even how their mood has
changed—but those around them do. When you try to enlighten such patients, they don’t 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 haven’t 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 Argentina—one 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 psychotic—a 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 can’t make a diagnosis solely on the basis of the
symptoms. The patient must also meet other conditions, outlined in Table 2 66. We’ll 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.” That’s 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
Mania
57
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
course—perhaps 3 months of symptoms before it spontaneously resolves into either a depression
or a normal mood. Even knowing nothing about an individual’s actual symptoms, clinicians
often strongly suspect bipolar I disorder based solely on a typical course of illness—episodes 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 males—the
ratio is about 3:2. Although the range is broad, on average it begins around age 25—even 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 risk—about 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 individual’s 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.
Mania
58
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
inheritance—the 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 isn’t synonymous with heredity; with a concordance rate less that
100%, there’s 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 life’s 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 opposite—that 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 didn’t drink,
many mania patients do abuse alcohol. They may be trying to modify their own high moods—an
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
Mania
59
fewer side effects, but overall lithium provides the greatest degree of improvement for the most
patients. For some patients, however, it isn’t 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 doesn’t 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 doesn’t 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 don’t 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 we’ll 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 doesn’t 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
Mania
60
another mood stabilizer, an antipsychotic, or a benzodiazepine. Even maintenance ECT might be
needed in rare cases.
The physician’s approach to the patient
How best to approach the mania patient strongly depends on severity. It’s 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, I’ve 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 mania—if you haven’t 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, won’t 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 we’re 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 safety—yours and the patient’s. 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 facility’s 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 don’t 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
61
Mania
to taper off the antidepressant medication—while 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 years—as 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 don’t need treatment between episodes, others don’t 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 mania—and
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 doesn’t.
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 don’t
have hallucinations or delusions or require hospitalization—either 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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Mania
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. We’ll 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 don’t 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 pattern—they 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
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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.”
Sal’s fall-winter depression symptoms included insomnia, low mood, reduced appetite, loss of
interest, and ruminations. Although he wasn’t 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 wasn’t delusional—he 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 SAD—including 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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Mania
As depicted in the riveting 1994 film “The Madness of King George,” these symptoms sound
like mania. However, George’s underlying condition was probably porphyria. Other medical
conditions that can cause manic-like mood swings include AIDS, brain tumor, cerebrovascular
accident, cryptococcosis, Cushing’s syndrome, epilepsy, head trauma, Huntington’s 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 up—an excellent demonstration of how important it is to pay attention to the longitudinal
course of the patient’s 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, Carl’s 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; he’d 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 don’t 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,
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Mania
Francine, persuaded him to return to his psychiatrist; after half an hour of discussion, he
accepted a recommendation for treatment.
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 Carl’s 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 Carl’s 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. It’s
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. It’s the best account
we have of a bipolar patient’s inner life.
66
Mood disorder tables
Symptoms
Severity
Exclusions
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
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.
Clinical distress or
impaired work, social,
personal functioning
Not GMC
Not substance-related
Not mixed episode
Not within 2 months of
bereavement (unless
severe†)
1+ of:
Psychosis
Hospitalized
Impaired work, social,
personal functioning
Not GMC
Not substance-related
Not caused by somatic
therapy*
Not mixed episode
A distinct change that
others can recognize
No psychosis
Not hospitalized
Not GMC
Not substance-related
Not caused by somatic
therapy*
1+ of:
Psychosis;
Hospitalized;
Impaired work, social,
personal functioning
Not GMC
Not substance-related
Not caused by somatic
therapy*
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
Mixed
Manic
Mood, duration
Hypomanic
Major depressive
Table 1. Symptoms and other criteria of mood episodes.
Mania and depression
for 1+ wks
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
Meets full criteria for both manic and major
depressive episodes
Bipolar II
mood
disorder
Bipolar I
mood
disorder
Major
depressive
disorder
Table 2. Combining mood episodes into mood disorders.
Mood episode
Exclusions & Other Features
Types of Pattern
1+ major
depressive
episode(s)
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
Single depression
Recurrent depressions
1 or more manic
episode(s)
May be major
depressive
episode
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
Single manic episode
Most recent episode manic
Most recent episode hypomanic
Most recent episode depressed
Most recent episode unspecified
1+ major
depressive
episode(s)
1+ hypomanic
episode(s)
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
*Somatic therapy: medication, ECT, bright light
†Severely impaired functioning, severe preoccupation with worthlessness, ideas of suicide, delusions or hallucinations, or slowed
67
Mood disorder tables
Description
Criteria
Can apply to:
Mood reactivity, cheerful
with good fortune, sad
with disappointment
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
Major depression
Dysthymia
Bipolar I depressed
Bipolar II depressed
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
With
seasonal
pattern
Major depression
Bipolar I depressed,
manic, mixed
Bipolar II depressed
Major depression
Bipolar I depressed
Bipolar II depressed
Major depression
Bipolar I depressed,
manic, mixed
Bipolar II depressed
Full remission between
two most recent episodes
In past year, 4+ episodes
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.
Major depression
regularly begins at a
particular season of the
year, as does full
recovery or change of
polarity.
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.
With
rapid
cycling
With/
without
full
interpisode
recovery
With
postpartum
onset
With
melancholic
features
With
catatonic
features
With atypical
features
Table 3. Mood specifiers that apply to current or most recent mood episodes and to dysthymic disorder.
Disregard episodes
where there is a clear
precipitant, such as
being unemployed
every summer.
68
Mood disorder tables
Symptoms
Severity
Exclusions
Many periods of
hypomania plus many
periods of mild
depression for 2 years;
longest symptom-free
period is 2 months
Hypomania when high; when depressed,
does not meet criteria for major
depression
Clinical distress or
impaired work, social,
personal functioning
Depressed, or appears
depressed to others
most of the day, most
days for 2 years; longest
symptom-free period is
2 months
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
Clinical distress or
impaired work, social,
personal functioning
Substance
use
Depressed or loss of
interest or pleasure, or
elevated, expansive,
irritable
Duration not specified
History, physical exam or laboratory
evidence that either:
Symptoms developed within 1 month of
intoxication or withdrawal, or
Medication use caused symptoms
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.
Depressed or loss of
interest or pleasure, or
elevated, expansive,
irritable
Duration not specified
History, physical exam or laboratory
evidence suggest a GMC has caused
symptoms.
Clinical distress or
impaired work, social,
personal functioning
Not solely during delirium
No other disorder better
explains symptoms.
Depressive symptoms
begin within 3 months
of stress; resolve <6
months after stressor
ends
Patient is sad, tearful, hopeless
Distress > expected for
stressor, or impaired
work, social, personal
functioning
Doesn’t fulfill criteria for
other Axis I disorder;
Not bereavement
Major depressive, mixed
or manic episode; 1+
months continuously ill
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
Schizo- Adjustment
affective disorder w/
depressed
mood
Dysthymic
Cyclothymic
Mood, duration
General
Medical
Condition
Table 4. Symptoms and criteria of other mood disorders,
Chapter 5
Psychosis and Schizophrenia
If you’ve ever had a dream in which you were being watched, perhaps followed, where everyone
knew something you didn’t, then you’ve had a taste of what it is like to be psychotic—except
that if you’re psychotic, it’s 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 he’d 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 magazine’s cover photo of Pope John 23 was really one of him.
(Supporting evidence: he noted that John wasn’t the Pope’s original name, and that 23 was
his, John Nash’s, 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
70
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.
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 (she’d 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 fixed—the 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 real—sometimes 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 emotion—no 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
degree—for many years his attention was so preoccupied by his delusions that he could do little
math.
71
Psychosis
Other negative symptoms are alogia—talking very little, even when the situation calls for
extended speech; and anhedonia—the 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 Nash’s
letter quoted in the vignette demonstrates a degree of disorganization.
Disorganized behavior. When severely psychotic, John’s behavior was occasionally
disorganized—for 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 patient’s threats, either by reporting them to the police or by other means. Patients with
schizophrenia often become suicidal, however, and 10–15% eventually take their own lives. The
risk of either tragic outcome—suicide or violence against others—is 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 it’s 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
Psychosis
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 people’s emotions—laughing at
someone else’s 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 recommendations—like 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
73
hallucinations). Their sleep may suffer; relatives sometimes note that they hear acutely ill
schizophrenia patients pacing and mumbling to themselves throughout the night.
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 subtypes—typically, 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 understandable—carrying 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 doesn’t 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: You’ll 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 doesn’t 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 shouldn’t
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 patient’s 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,
74
Psychosis
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
75
On the other hand, a poor outcome may be heralded by:
•
•
•
•
•
•
•
•
•
•
•
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
doesn’t 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 large—perhaps
around 10%, depending on the study—but 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 today—about 1% of all adults have it—and 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 poverty—the social drift theory of schizophrenia.
Psychosis
76
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 5–10% chance of developing the disease. (One of John
Nash’s 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. We’ve already mentioned the three personality
77
Psychosis
disorders—schizoid, schizotypal, and paranoid—that 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
don’t 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 dangerous—as well as delay treatment that is appropriate and effective.
Accurate diagnosis depends on knowing not just the symptoms but the patient’s 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 don’t 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 decline—possibly 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 4–6 week trial is generally
accepted as a standard treatment trial for any of the antipsychotic agents. If the first choice isn’t
effective, risperidone (Risperdal) or quetiapine (Seroquel) instead might be. For the first month
Psychosis
78
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 haven’t
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 aren’t 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 who’s
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. That’s why clozapine is usually reserved for patients who simply don’t 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
skills—for example, how to request cooperation without alienating the patient. This information
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Psychosis
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 µg/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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Psychosis
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 subtype—bipolar or depressive.
There are some serious problems with these criteria, besides the fact that few of Kasanin’s
original patients would qualify. For one thing, they aren’t 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, we’ve 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. That’s because
this term is really just a place-holder, an acknowledgment that the clinician isn’t 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
patient’s 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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Psychosis
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 haven’t 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 one—delusions.
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 wasn’t left alone, he was finally committed to the county mental health unit.
His son told the caseworker that Orville didn’t 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:
Persecutory—like Orville, the patient feels in some way intentionally cheated, drugged,
followed, slandered, or otherwise mistreated. This is by far the most common subtype.
Grandiose—the patient has a special talent or identity, such as being a rock star or Jesus. This
type appears to be rare.
Erotomanic—someone, often of status higher than the patient’s (such as a television actor), is
in love with the patient.
Jealous—the individual’s partner has been unfaithful. This may be more common among men
than women.
Somatic—these people believe that they have some physical illness or defect, such as
delusional infestation by parasites.
These delusions are not bizarre—that 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 Wilson’s disease, cerebrovascular
disease, and dementia.
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82
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 don’t seem to work, some patients appear to respond to an SSRI. Psychotherapy
alone is of no value, but the family’s 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 didn’t 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-husband’s, and it told her to stop the interferon because it was causing her hair to
fall out. Laboratory testing showed that Helen’s thyroid gland had almost stopped
working—probably 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 “Don’t tell them about your drinking!” and “Why don’t 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 rates—in 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, Cushing’s syndrome, epilepsy,
Huntington’s disease, hyper- and hypo-parathyroidism, hyper- and hypo-thyroidism, Lyme
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83
disease, normal pressure hydrocephalus, porphyria, and tertiary syphilis. And that’s just a few of
them.
As with Danny, a mistaken diagnosis can complicate a patient’s 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 physician’s 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. “It’s 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 patient’s 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 what’s 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 emotion—for example, sad, angry—and 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, I’d feel pretty upset, too.”
On the other hand, don’t 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 patient’s
hallucinations or delusional thinking.
The same line of thinking suggests we shouldn’t 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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Psychosis
•
•
•
wonder if there could be some other explanation…” or “I’m having trouble understanding
what you’re telling me, but I recognize how important it is to you.”
“Why don’t people believe me when I say [the CIA taps my phone]?” is the sort of question
you might well be asked. It’s 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. “I’ll 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 says…so we have to comply” puts you and the patient on the same side of
nearly any issue. “I’ll be glad to speak with your doctor about more privileges, but I suspect
I’ll be rebuffed.”
You may have to continually refocus the patient’s attention. “Yes, I understand that you
worry about the voices in the hallway. But let’s 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 don’t 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 area—calmly but rapidly. Don’t argue, and don’t 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. “It’s 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 who’s 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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Psychosis
to a month. But what about patients whose psychotic illness has lasted just a couple of weeks?
Well, that’s 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, don’t expect to encounter a lot of these people; in all my years of practice, I’ve
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 I’ve 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 à deux (the madness of
doubles, or double insanity), though instances are recorded that involved three or more
individuals—always 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 me—I’d love to hear.
Sidebar: Violence and Mental Disorders
The unhappy truth is, psychiatrists are little better than anyone else at predicting violent acts
accurately—it’s hard enough to foresee behavior within the next few hours or days, let alone
weeks or months into the future. Over the years, we’ve learned some of the factors that are
associated with violent behavior, but the leap we’d 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 she’d helped her boyfriend construct in his grandmother’s 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
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86
noted that she’d resumed drinking, and that several times she’d 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 wouldn’t 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 didn’t know, but she thought it might be loaded.
Many clinicians might decide that Brent’s 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 diagnoses—schizophrenia,
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 (Brent’s
diagnosis) carries a lower risk of violence than do some personality disorders. A number of
physical brain diseases can also lead to violence—head injuries, seizure disorders, Alzheimer’s
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 doesn’t usually pose a problem: patients are often
quite willing to admit to prior offenses. Brenda’s 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 we’d 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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Psychosis
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.
Here’s 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
Schizoaffective Schizophrenia
disorder
6 months or more
1+ month of sx (less, if
treated).
For 2 weeks, delusions
or hallucinations w/o
prominent mood sx
Shared
psychotic
disorder
Brief
psychotic
disorder
Schizophreniform
psychosis
1–6 months
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
Exclusions
Material impairment in
patient’s work, socialization,
self-care
Mood disorder
Schizoaffective
Gen med condition
Substance-related
Developmental disorder
Mood episode symptoms
present during substantial part
of active and residual portions
of the illness
Gen med condition
Substance-related
“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
One day to one month,
with full return to
previous functioning
level
1+ of:
Delusions
Hallucinations
Disorganized speech
Disorganized behavior
Mood disorder
Schizophrenia
Schizoaffective
Gen med condition
Substance-related
Begins after a close
associate becomes
delusional
Delusion is similar in content to the
first person’s delusion
Mood disorder
Schizophrenia
Schizoaffective
Gen med condition
Substance-related
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Psychosis
Review
When he was 17, Jason’s 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 hadn’t 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 lovers—his mother’s 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.
Jason’s 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 didn’t need it anyway; he wasn’t 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, Jason’s 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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Psychosis
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 Jason’s symptoms have to
be like? [p 79]
10. Suppose Jason had had only delusions and no other psychotic symptoms—how 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 Douglas’s character was in
love with her—to 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 aren’t usually the one’s who are
violent.) More recently, Ian McEwen wrote a gripping portrayal of the disorder in Enduring
Love. It’s 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 effects—an uneasy
sense of apprehension; a decreased ability to concentrate with a nagging sense of unreality;
nameless fear of death or—the 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 it’s 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 can’t explain them: life’s events and circumstances
also play powerful roles.
All anxiety disorders have in common one or more of the following features:
Anxiety—an uneasy state of apprehension that exceeds any actual threat you may be facing
Panic—acute anxiety accompanied by bodily symptoms such as racing heart, trouble with
breathing, and uncontrollable trembling
Phobia—anxiety where you can pinpoint the cause, which exceeds any actual threat
Stress—which causes anxiety (or fear)
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Anxiety and Panic
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 Dow’s 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, Winfield’s 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 couldn’t 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
Winfield’s 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 you’re afraid that you are going crazy or
your heart’s 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 life—a 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 isn’t
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 they’d 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 don’t—or 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 doesn’t 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, we’ve 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 isn’t unusual to awaken at night with them. For weeks,
they may come in daily waves—then 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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93
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.
Winfield’s doctor approached his PD from several angles, beginning with some education.
He felt reassured when he learned that he didn’t 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 hadn’t had a panic attack for days. This
Anxiety and Panic
94
wouldn’t have been especially noteworthy—he had sometimes gone for weeks at a time
without one—but 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.”
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 don’t 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. That’s 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. That’s 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 12–18 months before attempting to taper it. Relapses aren’t uncommon; they
indicate restarting medication.
Treating agoraphobia
Within a few weeks, Winfield’s 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
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cognitive-behavioral therapy, assertiveness training, meditation, and relaxation. Other than
managing associated panic attacks, drugs are not generally indicated for agoraphobia.
Course of illness
Although most people seek treatment soon after the first attack—panic is just too uncomfortable
to tolerate—left 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 time—another 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 I’m 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:
There’s 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 stress—someone 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 life’s most stressful events—the 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), you’ll 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 don’t have to do—listening 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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Anxiety and Panic
•
•
•
•
•
•
•
•
•
•
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 hour—preferably more—each week.
Nothing helps you through tough times like knowing what to do; establish routines (but
brace yourself for change, when it’s 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 isn’t 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—
isn’t. 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. We’ll cover the second of these later (page 107).
Symptoms and diagnosis
With phobias, the threat is something you can identify—such 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 Snicket’s character, Aunt Josephine, had a morbid fear of real estate
agents). Besides agoraphobia, the two names you’ll still encounter are acrophobia (fear of
heights) and claustrophobia (being closed in).
Specific phobias are what most people associate with the term “phobia”—when 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
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multiple phobias; for example, composer Richard Rogers feared almost anything having to do
with travel, including bridges, elevators, and tunnels.
Andrea’s 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 didn’t seem to help. She had
also tried several medications and self-hypnosis, but she remained fearful. “I know it’s way
out of proportion,” she said, “but job or no job, I don’t think I can survive this way.”
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 plans—after 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 classify—the
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 don’t fear the thing itself but the imagined outcome. For example, Andrea
would be perfectly happy to be near an airplane, if she knew she didn’t 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 they’ll 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 doesn’t 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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OCD
Anorexia nervosa
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 isn’t hard to do if
it is mild enough, but then, most clinicians probably wouldn’t dignify it with the term “phobia.”
Living someplace where you won’t encounter the stimulus is another coping strategy. For
example, city dwellers don’t meet many snakes (of the sort that slither, anyway), and Oregonians
don’t have to endure many thunderstorms. In fact, most patients seek treatment because of
something else entirely—often, a comorbid condition.
However, certain phobias demand resolution—for 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 isn’t practical for thunderstorms, which are hard to schedule. Then, CBT and other
techniques can be used, depending on the feared stimulus, the patient’s willingness, and the
therapist’s 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 person’s
physiology atypically. When people with needle phobia encounter needles, they don’t 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 doctor’s 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 couldn’t 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 couldn’t 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
hadn’t 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 stammer—he 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 he’d 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, he’d avoid eye contact so he wouldn’t 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 I’m
afraid I’ll 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 concentration—the 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 socialize—which 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 can’t 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 wouldn’t diagnose social
phobia unless it materially impairs the individual’s life or causes a great deal of distress.
(Gordon’s 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 (“I’ll 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 aren’t 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 adulthood—50% 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 phobias—as 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). Parkinson’s patients have
elevated rates of social anxiety disorder.
Treating social phobia
A patient’s 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 “I’d look like a nerd” response with “I’d 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 homework—for 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 didn’t 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 couldn’t
seem to turn off the worrying,” he later told his therapist. A year earlier, he had two
important things to worry about—finishing his thesis and finding a job. Though he had
managed to accomplish both, that hadn’t stopped the worrying. “Now I’m 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 diagnosis—two that must be present, and one
that must not.
•
•
•
A typical GAD patient worries about many things—job performance, school grades, children’s health, finances, relationship with a lover—even 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 won’t 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 isn’t what the GAD patient worries about, but the worry itself.
GAD patients worry much of the time. As one man put it, “It’s 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 don’t 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 hospital—will 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 don’t 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 entity—perhaps 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
isn’t that simple, especially if the worries fall into the GAD pattern. It’s 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 won’t 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 didn’t 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, Lyman’s 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 you’ve ever had a minor car accident, you’ve probably had some of these physical reactions:
your heart beats fast, you’re 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 longer—perhaps even a lifetime—and 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 couldn’t 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 couldn’t really keep her
mind on anything, even reading. She wouldn’t talk to a friend who had enlisted with her,
and she wouldn’t 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 don’t 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 experience—talking
with army friends, even using a knife. Some people develop amnesia for aspects of the
traumatic experience.
Arousal. Aretta’s 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 wouldn’t have to be hurt or even threatened to develop symptoms of PTSD—watching
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 response—involuntary behaviors learned during the course of
the traumatic experience—which 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.
Aretta’s therapist asked her to describe the rape, as if it was occurring at that moment, and
to report what she could see in her mind’s eye. It took some persuasion before she’d 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 don’t 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. That’s 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
doesn’t prevent PTSD, it actually makes some people worse. Antianxiety drugs, taken just after a
severe automobile accident or other trauma, don’t 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 who’s 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. That’s 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, it’s 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
2–28 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 isn’t 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
110
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.
Obsessive–Compulsive Disorder
We sometimes speak casually of being “obsessed” with a thought or idea; we may describe
someone’s behavior as being “compulsive.” Then, we’re talking about simple exaggerations of
normal thinking and behavior—what 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:
Paulette’s 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, she’d 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, “It’s stupid and
I hate it, I just can’t help it. I just can’t 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 worked—she 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 wife’s need
to “protect” their daughter by joining the extreme behavior. Judy only redoubled her
efforts, which made him even angrier at his daughter. “She’s dragged the whole family
down,” he grumbled. “She makes a production out of what normal people take for
granted.”
Anxiety and Panic
111
Symptoms and diagnosis of OCD
Paulette couldn’t control her thoughts about contamination, and she couldn’t 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).
Paulette’s 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 procedure—step 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.
Paulette’s 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 Paulette’s
mother may try to ease the person’s 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. That’s partly why OCD was once thought to be rare—shame
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
112
Impulse control disorders (hair-pulling, pathological gambling)
Psychotic disorders
Adjustment disorder
Everyday superstitions and checking behavior
Obsessive-compulsive personality disorder*
Sidebar: Obsessed with Imperfection
Stunning and statuesque, at age 23 Tamara was consulting her third plastic surgeon about
her nose. The first two hadn’t thought they could improve on nature’s gifts, but Tamara
was unconvinced. “I’m 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 don’t 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 immune—ankles, 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, 12–16 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.
Anxiety and Panic
113
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 Tourette’s 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 aren’t thoroughly worked out, several
studies have found that OCD in a relative increases a person’s risk for the disease fivefold. There
is also a familial link to Tourette’s 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 Tourette’s
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, Paulette’s 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
Anxiety and Panic
114
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 200–250/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. Paulette’s
family had to stop using gloves and decontaminating the house—these behaviors reduced
Paulette’s 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 they’ve 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 won’t find physical illnesses and substance use as causes of most of the named disorders
we’ve covered in this chapter, but that doesn’t mean we can relax our vigil for medical causes of
anxiety. For example, though repetitive behaviors occur in Tourette’s disorder and in temporal
lobe epilepsy, they don’t 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, you’ll find that many of them include anxiety.
115
Anxiety and Panic
Review
Isaac had his first attack when he was 16. It was during an algebra test that his heart started
pounding so hard he couldn’t 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, he’s had
episodic attacks of feeling acutely frightened and disoriented.
Beginning abruptly and without warning, Isaac’s attacks rapidly swell to a terrifying
climax. His heart pumps so fast that he can’t 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.
Isaac’s attacks have occurred in a variety of circumstances—at 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, “I’m 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 Isaac’s symptoms. [ p 92]
3. Suppose Isaac’s 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]
116
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
Social phobia: A strong,
repeated fear of showing
anxiety sx or
embarrassment while
watched by others
Generalized anxiety
disorder
Exclusions/Other
Not caused by substance use, GMC
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
Meets criteria for agoraphobia†
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 patient’s usual
routines or personal, social, work functioning
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.
Does not have agoraphobia
Not caused by substance use, GMC
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)
Blood–injection–injury
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 doesn’t provide
the focus of the anxiety and worry
Doesn’t occur only during mood,
psychotic disorder or PTSD or pervasive
developmental 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
Substance Misuse
Table 7b. Simplified Criteria for DSM-IV Anxiety Disorders (cont.)
Disorder
Symptoms
Obsessivecompulsive
disorder
Posttraumatic
stress 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)
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 patient’s 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 2–29 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 patient’s
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 patient’s 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.
118
Substance Misuse
Table 8. Mental/emotional symptoms associated with selected physical illnesses
Dementia
Inattention
Slow Thought
x
Delirium
x
Disorientation
x
↓ Memory
Suicide Ideas
x
PTSD
Hallucination
s
Delusions
x
x
x
x
x
x
x
x
x
x
x
x
Cognitive symptoms
↓ Judgment
Catatonia
Withdrawal
x
x
Labile mood
x
Obses/comp
Anxiety
x
x
Panic
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
Cushing’s
Deafness
Diabetes mellitus
Epilepsy
Fibromyalgia
Head trauma
Herpes encephalitis
Homocystinuria
Huntington’s
Hyperparathyroidism
Hypertension
Hyperthyroidism
Hypoparathyroidism
Hypothyroidism
Kidney failure
Klinefelter’s
Liver failure
Lyme disease
Meniere’s
Menopause
Migraine
Mitral valve prolapse
Multiple sclerosis
Myasthenia gravis
Neurocutaneous diseases
Normal pressure hydrocephalus
Parkinson’s
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
Depression
Emotional/behavioral Symptoms
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Further Learning
I don’t have nearly enough recommendations for works that will guide you “inside” the mind of
people who have anxiety disorders. I’d 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, doesn’t 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 don’t 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. We’ll 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 he’ll 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 didn’t “have to have
it.” Remembering his own youthful misadventures, Del couldn’t bring himself to confront
Eva about her behavior.
*
As we’ll see later, the term “abuse” has a special and specific diagnostic meaning. It is to avoid confusion that,
throughout this book, I’ve 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
it’s confusing? I’ve opted for clarity.
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Del’s 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 Del’s shoulder and cried, “I’m a hopeless
alcoholic, I’m nothing without a drink!” The following winter, he was found frozen to
death in an alleyway behind the liquor store.
DEPENDENCE AND ABUSE
Eventually, we all overuse something, even if it’s 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, doesn’t 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 imprecise—we
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 substance—or a related one—to 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 dependent—he 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 Stanley’s shakiness and nausea. However, you don’t 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 doesn’t 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 Marcia’s only symptoms of dependence are these: she often drinks
more alcohol than she intends, keeps using cocaine on the weekends despite her doctor’s
warning that it’s causing her severe mood swings, and she has tried Nicorette gum, a
nicotine patch, and group therapy—twice—to try to kick her cigarette habit.
Marcia doesn’t 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 dependence—in
short, they aren’t 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 wouldn’t 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 she’d 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 don’t appear to be hierarchical: criteria for abuse tend to be sprinkled among
dependent patients, not clustered tightly together, and many dependent patients don’t also have
abuse criteria. Furthermore, there are still other patients who have been problematic users
without qualifying for either substance dependence or abuse—so-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. It’s 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, we’d be awash in chemically
dependent people.
We might start by asking, what’s the attraction? One big factor, especially for the young and
impressionable, is the siren song of peer influence—glamour 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 people’s 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 doesn’t 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
wouldn’t 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 physician’s 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 user’s decision to change.
Frank discussion. Here is my first approach, almost every time. It uses evidence from the
patient’s 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 patient’s 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 him—with
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 parent’s legal leverage to command evaluation
and treatment is strong—assuming 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 same—even unwelcome—truths, 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
modalities—drugs haven’t been developed, psychotherapies haven’t been explored—so 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
don’t 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 diagnosis—perhaps depression, social phobia, or another
anxiety disorder. When another mental diagnosis (dual diagnosis) is found—which is the case in
over half the people who misuse drugs and alcohol—it 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 patient’s commitment to sobriety seems to waver, you might use
motivational interviewing to highlight the conflict between life goals and substance use—for
example, that you want to be a good provider but, because of drinking, often don’t 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.
Here’s a sample of what I’d 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 don’t
be alone—keep 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 doesn’t work. The future depends on freedom from, not of, substance use.
• Change the environment. It’s 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 patient’s 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 use—closet 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 patient’s 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 isn’t a disaster. Patients slip all the time; it’s 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, don’t 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, we’ll 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 detail—lung 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 use—glamour, peer acceptance,
feeling grown up—are 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, Miranda’s 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 don’t 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 isn’t 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, I’d 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 don’t 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 didn’t 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 drinker’s history.
• Wernicke’s encephalopathy (thiamine) with nystagmus, ataxia, confusion.
• Korsakoff’s 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, Dupuytren’s contractures, testicular atrophy, and male breast enlargement occur late.
• Impotence.
• Fetal alcohol syndrome: Low IQ, facial abnormalities (small circumference, small midface,
epicanthic folds, indistinct philtrum—the 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 25–50 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 12–18 hours and peaks between
24–48 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 7–38 hours after the last drink. Other than short-term use of benzodiazepines,
they don’t 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 5–15 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 isn’t 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). Acamprosate’s mechanism of action isn’t exactly known; it may reduce
the dysphoria and sleep disorders that accompanies a heavy drinker’s 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 hasn’t 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 destructive—so 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, I’d
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 don’t 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 alcohol—to 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 what’s called the “amotivational syndrome”—apathy, poor
concentration, social withdrawal, and loss of interest. In teenagers, heavy use can slow emotional
and social development. Marijuana is acutely dangerous if you’re 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 don’t 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, don’t 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 drugs—cocaine 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, they’ll 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 won’t 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 person’s 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 Vick’s 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.
Methamphetamine’s 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.
Waddell’s 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 wasn’t 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
weren’t “real,” and she had never experienced one of those bad trips that a friend once
described—he 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 wasn’t scary, but I sure wanted it to go away.”
With its duration of effect 8–12 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 trip—as with Miriam’s friend, it can occasionally cause marked anxiety and paranoia.
Because frequent use weakens its effects, most people don’t 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
flashbacks—aspects of a previous trip replay themselves spontaneously, without further drug
use. If hallucinations persist, antipsychotic agents may be necessary. Then an unresolvable
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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.
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 didn’t 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 opioids—e.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
Schedule II
High
Schedule III
Less than I/II
Schedule IV
Lower than III
Schedule V
Lower than IV
No
Yes
Yes
Yes
Yes
—
Severe physical or
psychological
Moderate or low
physical or high
psychological
Limited physical
or psychological
relative to III
Limited physical
or psychological
relative to IV
No
Rx only, 30 days**
Rx only
Rx only
—
Gammahydroxybutyric
acid (GHB); heroin;
cannabis (!); MDMA
(Ecstasy); psilocybin
(mushrooms); LSD;
methaqualone;
bufotenin (originally
extracted from toad
venom)
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,
5x in 6 months
anabolic steroids;
buprenorphine;
dihydrocodeine;
ketamine;
Xyrem (GHB)
for treating
narcolepsy;
paregoric;
dronabinol
(Marinal), a
synthetic form
of THC
5x in 6 months
Benzodiazepines;
zolpidem and
other “Z”
sleepers;
propoxyphene
(Darvon);
phenobarbital
and other longacting
barbiturates;
pentazocine;
Modafinil
Only for medical
purposes *
*
Codeine
preparations,
e.g., Robitussin
A-C; difenoxin
e.g. Motofen;
opium
preparations
such as Kaolin
Pectin P.G.
*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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Substance Misuse
Overall harm
Overall harm
Heroin
2.77
Cannabis
1.33
Cocaine
2.30
Solvents
1.27
Barbiturates
2.08
4-MTA
1.27
Street methadone
1.94
LSD
1.23
Alcohol
1.85
Methylphenidate
1.18
Ketamine
1.74
Anabolic steroids
1.15
Benzodiazepines
1.70
GHB
1.12
Amphetamine
1.66
Ecstasy
1.09
Tobacco
1.62
Alkyl nitrites
0.92
Buprenorphine
1.58
Khat*
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.
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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 couldn’t be sure. The next clear memory I have is waking up in his bed.”
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 brief—a few minutes to
under and hour—repeated 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 didn’t think about the way his parents were always fighting.
Because these CNS depressants severely reduce the blood’s ability to carry oxygen, the
inhalants can cause widespread destruction of the body’s 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, doesn’t 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 symptoms—nausea, muscle cramps, tearing, insomnia—are 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 location—it 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, I’d 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 Erik’s 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. That’s 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.
Substance Misuse
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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 can’t find a methadone program or don’t 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 sedative—by far, sedative withdrawal is the more dangerous syndrome.
The chances of eventually recovering from opioid dependency actually aren’t 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 anyone’s
success. And, like most of Erik’s 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 shouldn’t 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”) isn’t 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, it’s 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 recover—though 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.
Physician’s 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:
Substance Misuse
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Practice acceptance, and eschew reproach. Don’t express alarm, horror, distaste, and all the
other perfectly normal emotions you may be feeling. Your patients have experienced them
all—their own and from family, and they don’t need to hear the same thing from you.
Don’t dismiss treatment options, just because they haven’t worked in the past. It often takes
repeated * runs at the * before *.
Other than quitting your substance use, don’t make major changes. Specifically, don’t change
jobs, get a divorce, or move. I’ve 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 (“What’s the use?”) so many drug users experience.
Encourage participation in a 12-step program. I always bring up this option early—and often.
Don’t argue with someone who is intoxicated. It will happen especially on the telephone
when you’re on call; a patient will call up with concerns that you’ve dealt with, or tried to, in
the office. You’ll 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. (“You’ve had a lapse, not a relapse; and we’ve
identified another situation that’s dangerous for you.”)
Don’t 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 less—so don’t 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).
Don’t hesitate to be frank. Clinicians have the same feelings as anyone else, so we sometimes
feel reluctant to bring up discomforting subjects. You don’t 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 patient’s relatives and friends, the points I like to cover include:
• First (I remind them), it isn’t your fault. It’s 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,
there’s 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 won’t register.
Substance Misuse
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Listening to reasons for using doesn’t 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 won’t 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.
They’ll also have to deal with their own resentment.
143
Substance Misuse Tables
TABLE 1. Symptoms of substance intoxication and withdrawal and presence of dependence and abuse
Mariju
ana
Inhalants
Hallucinogens
Caffeine
Amphetamines,
cocaine
Alcohol,
hypnotics
sedatives/
anxiolytics
Substance The attraction
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
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
Euphoria, blunted mood,
extreme vigilance,
interpersonal sensitivity,
anger, anxiety, tension,
changes in sociability,
stereotyped behaviors,2
impaired judgment, poor job
or social 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
Reduced fatigue and drowsiness,
improved mood and
concentration;
Legally available everywhere, in
many different forms
Clinically important
distress or impaired job,
school, social, or other
functioning
Mild euphoria, sensory
distortions
Depression or anxiety,
ideas of reference,
persecutory ideas, fears of
insanity, poor judgment,
impaired 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
Giddiness, stimulation, loss of
inhibitions, an illusion of
strength; they are cheap and legal
(hence, available), which appeals
to children
Apathy, assaultiveness,
belligerence, poor judgment,
impaired school, job, or social
functioning
Reduced inhibitions (including
sexual), improved sociability,
brightened mood
Relaxed sense of well-being,
reduced inhibitions similar to
alcohol, dreamy fantasies
Nicotine
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
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
Euphoria, hallucinations,
“disconnectedness”
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
PCP
Opioids
Euphoria, reduced concern for
the present, indifference to pain
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
Depend/
Abuse
Depend/
Abuse
None, though
flashbacks
(hallucinations that
persist after the drug
is out of the system)
can occur
N/A
Depend/
Abuse
N/A
Depend/
Abuse
Neither
Depend/
Abuse
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
*
The symptoms aren’t 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.
Depend/
Abuse
Depend/
Abuse
144
Substance Misuse Tables
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
•During or shortly
after use, one or
more:
Slurred speech
Lack of
coordination
Unsteady walking
Nystagmus
Impaired
attention or
memory
Stupor or coma
•During or shortly
after use, 5+ of:
Restlessness
Nervousness
Excitement
Sleeplessness
Red face
Urination ↑
Gastrointestinal
upset
Twitching muscles
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
•During or shortly
after use,
perceptual changes
•During or shortly
after use, 2+ of:
Dilated pupils
Rapid heart rate
Sweating
Palpitations
Blurred vision
Tremors
Lack of
coordination
•During or shortly after
use, 2+ of:
Dizziness
Nystagmus
Lack of coordination
Slurred speech
Unsteady walking
Lethargy
Slowed reflexes
Slowed psychomotor
activity
Tremors
Muscle weakness
Blurred or double
vision
Stupor or coma
Euphoria
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
None
None
Other Other symptoms
specifiers
Maladaptive psychological/ behavioral changes
Table 2. Criteria for intoxication with psychoactive substances
None
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
•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
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.
145
Substance Misuse Tables
Table 3. Criteria for substance withdrawal
Use
Specific
Symptoms
General
criteria
Other
Alcohol/sedatives,
&c
•Heavy/prolonged
use before cessation
or reduction
Cocaine/
amphetamines
•Heavy/prolonged
use before
cessation or
reduction
Hallucinogens
Nicotine
[See table
footnote]
•Daily use for
several weeks
before
cessation/
reduction
Opioids
•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) isn’t 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.
146
Substance Misuse Tables
Table 4. Criteria for substance-related mental disorders
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 (can’t
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+
can’t 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
Intoxication or Withdrawal
delirium
Substance(s) involved
Also code
substance
dependence, if
appropriate
?
Substance
With Onset During
Intoxication or
During
Withdrawal
Code: With
delusions, with
hallucinations
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
Amphetamines
Cannabis
Cocaine
Hallucinogens
Inhalants
Opioids
PCP
Sedatives,
hypnotics,
anxiolytics
Other/unknown
Applies to:
Specify
Inclusions, exclusions,
Main symptoms
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 can’t better explain
Sx develop rapidly (hours to
days) and tend to fluctuate
during the day
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
Alcohol
Amphetamin
es
Caffeine
Cocaine
Opioids
Sedatives,
hypnotics,
anxiolytics
Other/unkno
wn
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
147
Substance Misuse Tables
Table 5 Use in millions
Substance
Lifetime use
in millions (%)
Previous month in millions
(%)
Tobacco
157.5 (70.5%)
65.4 (29.3%)
Alcohol
180.8 (80.0%)
12.5 (5.6%)*
Marijuana and hashish
76.4 (34.3%)
10.7 (4.8%)
Cocaine and crack
25.4 (11.2%)
1.2 (0.5%)
Tranquilizers
13.0 (5.8%)
1.0 (0.4%)
Hallucinogens and PCP
26.1 (11.7%)
0.98 (0.4%)
Stimulants
14.6 (6.6%)
0.79 (0.4%)
Inhalants
16.7 (7.5%)
0.62 (0.3%)
Sedatives
7.1 (3.2%)
0.17 (0.1%)
Heroin
2.8 (1.2%)
0.13 (0.1%)
Any illicit drug
86.9 (38.9%)
14.0 (6.3%)
*Heavy alcohol users (5+ drinks/day, 5+ days/month)
Review
While he was still in high school, Jerrald’s drinking was already getting out of hand. He’d 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, “I’ll drink with him, but I won’t ride with him.” And a couple of times, he hadn’t even
shown up for an important exam in calculus—and he planned to major in math when he hit
college. Nonetheless, when the chips were really down—as for the SATs, which he aced—he
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 drank—no more than once
or twice a month”—because 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 he’d gone through all the crack he’d been saving for a big party. The last
half of his senior year, after he’d 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 (“I’ve 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
pharmacology—he failed it outright, and was told he’d have to repeat his sophomore year. “You
know, more than once I’ve 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 Jerrald’s 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: it’s 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 Jerrald’s prognosis for a full recovery from [whatever is correct diagnosis might
be]. [p *]
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.
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