Laboratory Testing in Psychiatry
By Royce P Gray, MD; Alexander W Thompson, MD, MBA, MPHPurchase PDF
Laboratory Testing in PsychiatryPurchase PDF
We review common laboratory testing encountered in psychiatric practice. It seems likely that in areas where the most evidence exists driving laboratory testing (e.g., metabolic monitoring for people on atypical antipsychotics), testing still is not universally done, and we often do not adequately address the results. However, in areas where there is little evidence supporting the practice (extensive laboratory testing on people being admitted to a psychiatric hospitals), we order tests extensively. We cover common tests encountered in the use of antipsychotics, antidepressants, mood stabilizers, antiepileptic drugs, and lithium. We also discuss the role of thyroid, vitamin B12, and folate testing and the special circumstance of caring for those with eating disorders.
Key words: agranulocytosis, antidepressant, antiepileptic drug, antipsychotic, blood dyscrasia, clozapine, eating disorders, metabolic monitoring, QT interval, urine drug screen
Epidemiology of Mental Disorders
By Carolyn Turvey, PhD, MS; Stephan Arndt, PhDPurchase PDF
Epidemiology of Mental DisordersPurchase PDF
This review describes the contribution of psychiatric epidemiology to our understanding of the distribution and determinants of psychiatric disorders. First, it describes basic concepts within epidemiology, such as prevalence, incidence, case definition, bias, and confounding, and their specific meaning within psychiatric research. The two basic study designs in epidemiology, cohort and case-control, are then reviewed. This discussion includes a tutorial on how to calculate key measures of association: risk ratio and odds ratio. Major community-based studies in psychiatric epidemiology are then reviewed, focusing on the Epidemiologic Catchment Area Study, the National Comorbidity Study and the National Comorbidity Study Replication, the National Survey of American Life, the National Latino and Asian American Study of Mental Health, and the National Epidemiologic Survey on Alcohol and Related Conditions. The review concludes with a discussion of pharmacoepidemiology and how it is critical to our understanding of the full impact of psychiatric medications postmarketing. In the future, epidemiology will be revolutionized with “big data” collection in both institutional and community settings. Nonetheless, the basic concepts presented in this review will continue to be relevant and critical to drawing sound, evidence-based conclusions about the true nature, correlates, and causes of psychiatric disorders.
This review contains 6 tables, and 63 references.
Key words: case-control study, cohort study, community-based studies, measures of association, pharmacoepidemiology, psychiatric epidemiology
The Psychiatric Interview and Mental Status Examination
By Donald W. Black, MDPurchase PDF
The Psychiatric Interview and Mental Status ExaminationPurchase PDF
The interview and mental status examination are integral to the comprehensive patient assessment and typically follow a standard approach that most medical students and residents learn. The psychiatrist should adjust his or her interview style and information-gathering approach to suit the patient and the situation. For example, inpatients are typically more symptomatic than outpatients, may be in the hospital on an involuntary basis, and may be too ill to participate in even the briefest interview. Note taking is an essential task but should not interfere with patient rapport. The interview should be organized in a systematic fashion that, although covering all essential elements, is relatively stereotyped so that it allows the psychiatrist to commit the format to memory that, once learned, can be varied. The psychiatrist should start by documenting the patient’s identifying characteristics (age, gender, marital status) and then proceed to the chief complaint, history of the present illness, past medical history, family and social history, use of drugs and alcohol, medications, and previous treatments. A formal mental status includes assessment of the patient’s appearance, attitude, and behavior; orientation and sensorium; mood and affect; psychomotor activity; thought process, speech, and thought content; memory and cognition (including attention and abstraction); and judgment and insight. With the data collected, the psychiatrist will construct an accurate history of the symptoms that will serve as the basis for developing a differential diagnosis, followed by the development of a comprehensive treatment plan.
This review contains 1 figure, 3 tables, and 12 references.
Key words: assessment, differential diagnosis, interviewing, mental status examination, treatment plan
Classification in Psychiatry
By Donald W. Black, MDPurchase PDF
Classification in PsychiatryPurchase PDF
Classification in psychiatry has ancient roots but mainly took form in the 19th and 20th centuries. European and American psychiatrists brought to the fore careful observation and description of clinical course. Formal attempts to classify patients took root after World War II based on the exigencies of the time. The DSM-I was published in 1952 and summarized all the diagnoses in psychiatry. Diagnostic criteria were introduced in the DSM-III in 1980 to introduce reliability to the diagnostic process, and a multiaxial system was introduced to aid in the comprehensive assessment of patients, later dropped in the DSM-5. Dimensional measures were introduced to aid with patient assessment, although many categories were reformulated based on research findings. In the DSM-5, the diagnoses are listed in order of clinical importance. Residual categories exist for those who do not meet the criteria for a more specific disorder. Although the DSM-5 has been criticized, criteria-based diagnoses will persist until a system can be created based on etiology.
This review contains 2 tables, and 23 references.
Key words: classification in psychiatry, diagnostic criteria, DSM-5, Feighner criteria, International Classification of Diseases, Kraepelin
Quality of Care: Performance Measurement and Quality Improvement in Clinical Practice
By Sonali P. Desai, MD, MPH; Allen Kachalia, MD, JDPurchase PDF
Quality of Care: Performance Measurement and Quality Improvement in Clinical PracticePurchase PDF
Attention to the quality of care within the United States health care system has grown tremendously over the past decade. We have witnessed a significant change in how quality improvement and clinical performance measurement are approached. The current focus on quality and safety stems in part from the increasingly clear realization that more services and technological advancement are not automatically equivalent to high-quality care. Much of the discussion about cost and quality in health care is shifting towards the concept of value. Value is defined as health outcomes achieved per dollar spent (in other words, an assessment of the quality of care per cost). This chapter reviews the current state of quality improvement in health care and, because improvement cannot be determined without measurement, reviews several aspects of effective clinical performance measurement. Since many measures are already in place, the chapter describes some of the organizations involved in quality measurement and improvement, as well the approaches they utilize. It looks at the multiple strategies in place to improve quality, from process management to collaboration, from financial incentives to transparency, and reviews newer models of care delivery that may materialize in the near future. Tables list types of quality measures, characteristics to consider when developing a quality measure, and organizations involved in quality improvement and performance measurement. A figure shows strategies used by the federal government to spur performance measurement and quality improvement. This chapter contains 56 references.
The Neurologic Examination
By Nicholas J Beimer, MD; Douglas J Gelb, MD, PhDPurchase PDF
The Neurologic ExaminationPurchase PDF
All physicians, regardless of their medical specialty or the setting in which they treat patients, must be able to perform a neurologic examination. In the outpatient office, up to 9 to 10% of all symptoms suggest the possibility of neurologic disease and up to 5% of emergency department visits are due to primary neurologic disease. The neurologic examination is critical in triaging these patients, selecting diagnostic tests, and indicating management. This review covers how to think about the neurologic examination, the screening examination, and diagnosis-focused neurologic examinations with an emphasis on stroke, epilepsy, encephalopathy and coma, neurodegenerative diseases, neuromuscular disease, and functional disorders. The figure shows a conceptual approach to the neurologic examination. The tables list components of the screening neurologic examination, neurologic examination focus points for suspected stroke and suspected epilepsy, lateralization and localization of common seizure semiologies, and neurologic examination focus points for encephalopathy/coma, suspected neurodegenerative disease, suspected neuromuscular disease, and suspected functional neurologic disorders.
This review contains 1 highly rendered figure, 8 tables, and 14 references.
Key words: Neurologic examination, neurodegenerative disease, neuromuscular disease, neurologic screening
Clinical Trial Design and Statistics
By Julie Ann Sosa, MA, MD, FACSPurchase PDF
Clinical Trial Design and StatisticsPurchase PDF
A clinical trial is a planned experiment designed to prospectively measure the efficacy or effectiveness of an intervention by comparing outcomes in a group of subjects treated with the test intervention with those observed in one or more comparable group(s) of subjects receiving another intervention. Historically, the gold standard for a clinical trial has been a prospective, randomized, double-blind study, but it is sometimes impractical or unethical to conduct such in clinical medicine and surgery. Conventional outcomes have traditionally been clinical end points; with the rise of new technologies, however, they are increasingly being supplemented and/or replaced by surrogate end points, such as serum biomarkers. Because patients are involved, safety considerations and ethical principles must be incorporated into all phases of clinical trial design, conduct, data analysis, and presentation. This review covers the history of clinical trials, clinical trial phases, ethical issues, implementing the study, basic biostatistics for data analysis, and other resources. Figures show drug development and clinical trial process, and type I and II error. Tables list Food and Drug Administration new drug application types, and types of missing data in clinical trials.
This review contains 2 highly rendered figures, 2 tables, and 38 references
Collaborative Care Models in Psychiatry
By Danielle M. Gainer, MD; Karley B. Fischer, BS; Parvaneh K. Nouri, MPHPurchase PDF
Collaborative Care Models in PsychiatryPurchase PDF
Integrated care models allow a team of providers to interact in a systematic manner, producing cost-effective and superior outcomes for patients. The collaborative care model (CCoM), one type of integrated care, has emerged as one approach with over 80 randomized controlled trials to support its efficacy. In this model, a behavioral health provider offers evidence-based, brief interventions but also serves as a liaison between the patient, medical providers, and the psychiatric consultant. The team also monitors outcomes through a registry and provides a stepped care approach to adjust interventions collaboratively, as needed. If the barriers to integrated care implementation are surmounted, psychiatrists working as consultants in this model can provide care in an efficient and sustainable manner.
This review contains 5 figures, 5 tables, and 48 references.
Key Words: barriers to implementation, behavioral health provider, collaborative care, cost-effective, integrated care, psychiatric consultant, cost-effective, registry, stepped care
Overview of Psychotherapy in Psychiatry
By Allison Cowan, MD; Randon Welton, MDPurchase PDF
Overview of Psychotherapy in PsychiatryPurchase PDF
Psychotherapy continues to be an integral part of psychiatric practice. The rich, interesting history of psychotherapy in medicine and psychiatry set the background to current practice. Psychoeducation provides patients with necessary information and forms the basic building block for all other psychotherapies. Supportive therapy, cognitive-behavioral therapy, and psychoanalytic/psychodynamic psychotherapies constitute the core of the therapeutic styles, but dialectical behavioral therapy, eye movement desensitization and reprocessing, interpersonal psychotherapy, motivational interviewing, hypnosis, and group psychotherapy are also practiced in current psychiatry. Key therapeutic tenets from each of these disciplines are incorporated into the medical practice of psychiatry.
This review contains 5 figures, 4 tables, and 63 references.
Key words: cognitive-behavioral therapy, current psychiatric practices, dialectical behavioral therapy, psychiatrist as therapist, psychoanalytic psychotherapy, psychodynamic psychotherapy, psychoeducation, psychotherapy, supportive psychotherapy
By Erin Crocker, MDPurchase PDF
Supportive PsychotherapyPurchase PDF
Supportive psychotherapy (SPT) is a form of psychological treatment in which a care provider collaborates with a patient to help maximize his or her level of psychosocial functioning and adaptation to his or her current situation. Unfortunately, SPT is often limited to use by psychiatrists within psychiatric settings, even though patients with medical illness also benefit significantly from these interventions. There is arguably a need to incorporate training in brief SPT techniques into general medical education as learning to provide support to patients and help them function to the best of their ability during difficult times is an important part of the role that all physicians should be prepared to provide for their patients.
This review contains 4 figures, 3 tables, and 45 references.
Key words: alliance, boundaries, coping, empathy, frame, psychotherapy, relationships, supportive
By Anna Brandon, Ph.D,, MSCS, ABPP; Aimee Grause, PCNS; Jessica Schultz, PhD; Scott Fairhurst, PhD; Ceth Ashen, PhD; Ann Back-Price, MSN, APRN, IAAP; Olga Belik-Tuller, PhD; Scott Stuart, MD; Kaela Stuart-Parrigon, M.A.Purchase PDF
Interpersonal PsychotherapyPurchase PDF
Interpersonal psychotherapy (IPT) is an empirically validated treatment for affective, anxiety, and eating disorders. IPT rests on attachment theory and posits that individuals become distressed when they have interpersonal problems, conceptualized in IPT as transitions, interpersonal disputes, or grief and loss issues. IPT is short term, with a typical dosing range of six to 20 sessions followed by maintenance treatment to reduce the risk of relapse. Dissemination of IPT has greatly increased over the last decade, with several large-scale efforts in public health settings in the United States and abroad. We review the basics of IPT for depression and anxiety. We also describe its application to groups and adolescents. Recently developed clinical tools that have enhanced the delivery of IPT and have increased fidelity are described. Opportunities for training in IPT are also reviewed.
This review contains 10 figures, 1 table, and 71 references.
Key words: adolescents, anxiety, depression, grief and loss, group therapy, interpersonal inventory, interpersonal psychotherapy, interpersonal summary, maintenance psychotherapy, posttraumatic stress disorder
By Charles Stanfa, MD ; Hassan Majeed, MD; Donna Sudak, MDPurchase PDF
Cognitive-behavioural TherapyPurchase PDF
Cognitive-behavioral therapy (CBT) is an empirically supported psychotherapy shown to be effective and durable for the treatment of a variety of psychiatric illnesses. It is problem focused and conceptually driven. Cognitive restructuring, behavioral activation, exposure, and developing good action plans for out-of-session practice are tools that benefit patients for a lifetime. The purpose of this review is to provide an overview of the literature that supports the use of CBT, introduce the key elements of the therapeutic approach, and illustrate them with case examples. The structure of the session and the CBT approach to the therapeutic alliance are highlighted in the text. The review is enhanced by tables and figures that summarize the features of the therapeutic approach and by worksheets that may be used with patients.
This review contains 11 tables, and 63 references.
Key words: cognitive-behavioral therapy, cognitive restructuring, collaboration, behavioral activation, exposure
By Adam Brenner, MD; Michael Laney, MDPurchase PDF
Psychodynamic PsychotherapyPurchase PDF
Psychodynamic psychotherapy is an evidence-based treatment that historically had its origins in psychoanalysis. It is based on an appreciation that the past continues to interfere with the present through the persisting existence of relationship templates generated during development. These developmental experiences include ideas, wishes, and fears that are too disturbing for the patient to allow awareness but continue to exert their effects outside of conscious awareness. The psychodynamic therapist fosters an experience that allows for unconscious material to become more available, through free association, examination of resistance, and exploration of transference. As therapy progresses, the growth of the patient’s insight and the resumption of stalled developmental opportunities result in symptomatic improvement and an enhanced quality of life. Psychodynamic psychotherapy has both a long history and an expanding literature that will both reward further study and assist in the care and understanding of those sufferers who are seen by clinicians every day.
This review contains 5 tables, and 60 references.
Key words: attachment, autonomy, free association, identity, resistance, separation, therapeutic attitude, transference, triangular relationships, unconscious motivation
By Maurice Bulls, MEd; Sylvie Naar, PhDPurchase PDF
Motivational InterviewingPurchase PDF
Motivational interviewing (MI) has been established as an efficacious clinical approach for treating a range of emotional and behavioral concerns, both alone and in combination with other interventions. MI is a method of communication designed to increase intrinsic motivation and commitment to change. The MI method is consistent with self-determination theory that suggests that patient’s internalize motivation when he or she feels relatedness, competence, and autonomy support. MI is specified by an underlying perspective or spirit, a flow of processes, and a set of skills. MI spirit is defined by partnership, acceptance, compassion, and evocation. MI processes include engaging, focusing, evoking, planning, and maintaining. The primary MI skills are reflections, open questions, and providing information or advice in an MI style. This review presents an overview of these components with real-world examples. MI is grounded in research and highly applicable across many settings. The practitioner seeking to incorporate MI into practice will better facilitate behavior change and maximize human potential in diverse populations.
This review contains 5 figures, 6 tables, and 55 references.
Key words: behavior change adolescents, cognitive-behavioral therapy, medication adherence, mental health, motivational interviewing, obesity, self-determination theory, smoking, substance use
Couple and Family Therapy
By Jessica ChenFeng, PhD; Diane Gehart, Ph.DPurchase PDF
Couple and Family TherapyPurchase PDF
Evidence-based couple and family therapies have a robust and well-established evidence base as a cost-effective treatment for numerous conditions and are the treatment of choice for several childhood and adult mental health issues. This review provides a brief overview of systemic couple and family therapy principles and then reviews the evidence base for using these methods with specific disorders. Family therapy treatments have been identified as a primary intervention for several childhood and adolescent disorders, including conduct, alcohol and substance use, attention-deficit, autism, psychotic, mood, anxiety, and eating disorders, as well as certain physical disorders, including diabetes, enuresis, and asthma. For adults, the current evidence base supports couples therapy for major depressive disorder with couple distress, alcohol and substance use disorders, anxiety disorders, distressed couples, and interpersonal violence with certain batterers. In addition, couple and family therapy is indicated for certain adult chronic health conditions, including stroke, traumatic brain injury, spinal cord injury, cardiovascular diseases, cancer, dementia, and diabetes. The review concludes with a discussion of effective referral for and training in evidence-based family therapy approaches.
This review contains 6 figures, 5 tables, and 53 references.
Key words: ADD/ADHD, adolescent, childhood trauma, conduct disorder, couples therapy, depression, eating disorders, family therapy, marital therapy, mood disorder
Group Psychotherapy: Development of a Successful Group
By Wayne A. Bowers, PhDPurchase PDF
Group Psychotherapy: Development of a Successful GroupPurchase PDF
Group psychotherapy is a complex and integrative task that is designed to assist patients to better understand their problems and focus on creating change. Effective group therapy is characterized by the concept that the group functions as the agent of change. Primary among those concepts are curative factors that are used to intentionally facilitate group development and member change. In addition, there is an establishment of group norms that help leader and group members to function efficiently. A fully functioning group develops group cohesion, establishes goals that fit each individual member and the group as a whole, and effectively screens group members to enhance therapeutic productivity.
This review contains 2 tables and 24 references.
Key Words: curative factors, instillation of hope, development of socializing techniques, stages of group development, cohesiveness, norms in group therapy, group goals, screening group members
Group Psychotherapy: Group Therapist Leadership Skills
By Wayne A. Bowers, PhDPurchase PDF
Group Psychotherapy: Group Therapist Leadership SkillsPurchase PDF
Conducting group psychotherapy is a complex yet fascinating endeavor. To be effective, a group therapist must be intentional in their approach and implementation of interventions. Some basic skills that must be mastered include confrontation of group members and behaviors, emotional stimulation of the group and individual members, and the development and enhancement of group cohesiveness. Practical skills involve the overall structure of the group, providing feedback to members and the group as a whole, modeling effective communication and interpersonal behavior, and self-disclosure in nonjudgmental manner. A group therapist also engages members to be open about themselves and with others and displays effective interpersonal communication by working with a cotherapist to model both interpersonal bonding as well as effective conflict resolution that can be generalized to the outside world.
This review contains 1 table and 16 references.
Key Words: cotherapy, emotional expression, executive function, feedback, group leader skills and values, male and female co-therapists, self-disclosure, skills and interventions
Neurobiology of Addiction
By Alex Gogliettino, Program in Neuroscience; Sarah Yip, MSc, PhD; Yasmin Zakiniaeiz, MSc; Marc Potenza, MD, PhD; Zu Wei Zhai, PhDPurchase PDF
Neurobiology of AddictionPurchase PDF
Addiction is a disorder characterized by poorly controlled substance use despite negative health and social consequences. Additionally, the only behavioral addiction recognized in the main text of the DSM-5, gambling disorder, presents similarly to many substance addictions with respect to the underlying neurobiology and poorly controlled gambling despite negative consequences (e.g., financial, familial problems). This review first provides an overview of the diagnostic criteria for addictive disorders—both substance and nonsubstance—and subsequently reviews the extant literature examining epidemiology, including global prevalence and co-occurring disorders, as well as differences in addicted and nonaddicted groups with respect to genotype, brain function, and neurochemical systems. Last, the prognosis, quality of life, and current treatment strategies for addictions are discussed. The review also includes tables and figures to supplement the text, summarizes important points, and provides visual representations of tasks used to study cognitive aspects of addictions and addiction pathophysiology.
This review contains 5 figures, 5 tables, and 80 references.
Key words: brain function, cognitive function, epidemiology, functional magnetic resonance imaging, genetics, neurochemistry, positron emission tomography, treatment
Kleptomania, Pyromania, and Disruptive Disorders
By Eric W Leppink, BA; Jon E Grant, JD, MD, MPHPurchase PDF
Kleptomania, Pyromania, and Disruptive DisordersPurchase PDF
Chronic disruptive and impulsive behaviors, such as kleptomania, pyromania, and intermittent explosive disorder, are significant concerns for clinicians treating psychiatric disorders due to their persistence and potential legal ramifications. To date, only a few studies have assessed treatment options for pyromania, oppositional defiant disorder, intermittent explosive disorder, kleptomania, disruptive mood dysregulation disorder, and conduct disorder. This review discusses the clinical presentation of these disorders and the available literature on their treatment, focusing primarily on randomized controlled studies. Due to the paucity of available clinical studies for these disorders, however, case studies and open trials are mentioned for reference. Summaries of supported pharmaceutical and psychological interventions are provided for each disorder.
Key words: adolescents, aggression, crime, fire setting, impulsivity, stealing, theft, treatment
Feeding and Eating Disorders
By Patricia Westmoreland, MD; Phillip S Mehler, MDPurchase PDF
Feeding and Eating DisordersPurchase PDF
Feeding and eating disorders are defined by persistent disturbance of eating (or behaviors related to eating) with subsequent changes in consumption or absorption of nutrition that are detrimental to physical health and social functioning. The following eating disorders are described in the DSM-5: anorexia nervosa, bulimia nervosa, binge eating disorder, pica, rumination disorder, avoidant/restrictive food intake disorder (ARFID), other specified feeding or eating disorder (OSFED), and unspecified feeding or eating disorder (USFED). ARFID, OSFED, USFED, rumination disorder, and binge eating disorder are new additions to the manual and are first described in the DSM-5. The DSM-5 also provides severity specifiers—mild, moderate, severe, and extreme—for the diagnoses of bulimia nervosa and anorexia nervosa. This review describes the eating disorders enumerated in the DSM-5 and provides information regarding their genesis and course.
This review contains 8 tables and 79 references
Key words: avoidant/restrictive eating disorder, binge eating disorder, DSM-5, eating disorder, other specified feeding or eating disorder, pharmacotherapy, pica rumination, psychotherapy, unspecified feeding or eating disorder
Clinical Management of Feeding and Eating Disorders
By Patricia Westmoreland, MD; Anne Marie O’Melia , MDPurchase PDF
Clinical Management of Feeding and Eating DisordersPurchase PDF
Eating disorders are diverse in etiology and presentation and are best treated by a multidisciplinary treatment team (physicians, nurses, dietitians, and psychotherapists). Effective treatment includes combinations of behavioral management, psychotherapy, and psychiatric medication. Pica and rumination disorder are typically treated with behavioral management. Treatment of avoidant/restrictive food intake disorder and restricting or binge/purge anorexia nervosa usually requires nutritional and medical management before patients are able to benefit from psychotherapy or psychiatric medication management. There are currently only two medications FDA approved for treatment in eating disorders. Fluoxetine is FDA approved for the treatment of bulimia. Lisdexamfetamine was recently approved for the treatment of binge eating disorder. Novel therapies, such as deep brain stimulation, repetitive transcranial magnetic stimulation, and transcranial direct current stimulation, are being studied for the treatment of severe and enduring forms of anorexia nervosa.
This review contains 5 tables and 58 references
Key words: behavioral management, diversity, FDA approval, fluoxetine, lisdexamfetamine, multidisciplinary team, novel therapies, psychotherapy, psychotropics
Gambling Disorder and Related Behavioural Addictions
By Eric W Leppink, BA; Jon E Grant, JD, MD, MPHPurchase PDF
Gambling Disorder and Related Behavioural AddictionsPurchase PDF
Behavioral addictions are defined as behaviors characterized by the failure to resist an impulse, drive, or temptation to perform an act that is harmful to the person or to others. These disorders share many similarities with substance addictions but may have unique treatment considerations. This category of disorders includes many separate behaviors, but some of the most common are gambling disorder, Internet addiction, compulsive buying, and compulsive sexual behavior. Although research remains limited on the neurobiology and treatment of these disorders, some limited evidence to date can help guide initial treatment recommendations. Additional research will be necessary to clarify the optimal treatment approach for these disorders, however. This review provides a general discussion of available research related to these four disorders, including neurobiological, epidemiologic, and treatment considerations.
Key words: behavioral addiction, gambling, Internet, neurobiology, phenomenology, sex, shopping, treatment
Overview of Substance Use Disorders
By Timothy Ando, MD; Emily Morse, DO; Alexander W Thompson, MD, MBA, MPHPurchase PDF
Overview of Substance Use DisordersPurchase PDF
Substance use disorders are a major source of morbidity and mortality, contributing to a significant proportion of deaths in the United States and worldwide each year. A substantial rise in deaths related to drug overdoses in recent decades has drawn increasing public attention to this issue. However, the majority of individuals struggling with substance use disorders remain untreated. The financial costs and health burden are substantial. This review provides a broad overview of substance-related and addictive disorders. The evolution of the classification system is described, and the diagnostic criteria for the various substance use disorders are reviewed. Epidemiology and etiologic considerations, including neurobiological pathways, genetics, environmental influences, and dimensional risk factors, are examined. Finally, individual substances and their related disorders are reviewed, including alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, sedative/hypnotics, stimulants, tobacco, and other or unknown substances. Intoxication and withdrawal syndromes are described where applicable, and clinical management concepts are discussed.
This review contains 6 figures, 5 tables, and 71 references.
Key words: abuse, addiction, alcohol, caffeine, cannabis, dependence, diagnosis, DSM-5, epidemiology, hallucinogen, hypnotic, inhalant, intoxication, methamphetamine, nicotine, opioid, sedative, stimulant, substance use disorders, tobacco, tolerance, withdrawal
Alcohol Use Disorders and Clinical Management
By Daniel Rohlf, MD; Joseph Cocozzella, MD; Alexander Thompson, MD, MBA, MPHPurchase PDF
Alcohol Use Disorders and Clinical ManagementPurchase PDF
Alcohol use disorder (AUD) is the current DSM-5 designation for problematic and pathologic alcohol use. AUDs have a high prevalence in the United States and are commonly treated in psychiatric practice. They are associated with a wide variety of medical and psychiatric comorbidities. Effective treatment depends on tailoring treatment setting, behavioral psychotherapies, and psychotropic interventions to the individual patients. Three medications are Food and Drug Administration approved for the treatment of AUDs: naltrexone, acamprosate, and disulfiram. Several other medications (anticonvulsants and baclofen) have been studied, but their role in treating AUDs is uncertain. Naltrexone and/or acamprosate should be considered first-line medications for patients without contraindications. Disulfiram can be considered a second-line or first-line treatment in patients with appropriate support or those who prefer it. All patients who are diagnosed with AUDs should be referred to mutual support groups (i.e., Alcoholics Anonymous).
This review contains 3 figures, 5 tables, and 35 references.
Key words: acamprosate, Alcoholics Anonymous, AUDIT, brief interventions, disulfiram, gabapentin, naltrexone, topiramate, 12 step
Clinical Management of Drug Use Disorders
By James Jackson, MD; Timothy Ando, MD; Alexander Thompson, MD, MBA, MPHPurchase PDF
Clinical Management of Drug Use DisordersPurchase PDF
Despite mammoth efforts toward the treatment and prevention of substance use disorders in the United States over the past 30 years, they remain a significant public health concern and an all-too-common comorbidity among people with other forms of mental illness. Continued research into genetics, pharmacotherapies, psychotherapies, and epidemiology for substance use disorders results in huge amounts of new information for clinicians to assimilate each year. This review summarizes current diagnostic and categorical standards in substance use disorders, epidemiology, genetic and physiologic factors in addiction for each class, clinically relevant laboratory testing, evidence-based treatments, and prognostic considerations in substance use disorders. Specifically, sections cover cannabinoids, hallucinogens, opioids, sedatives, and stimulants.
Key words: benzodiazepines, cannabis, drug dependence, hallucinogens, MDMA, substance abuse, substance dependence, synthetic cannabinoids
Alcohol and Drug Withdrawal Syndromes and Their Clinical Management
By Alexander Thompson, MD, MBA, MPH; Andrea Weber, MD, MMEPurchase PDF
Alcohol and Drug Withdrawal Syndromes and Their Clinical ManagementPurchase PDF
Withdrawal syndromes are clusters of signs and symptoms that occur with cessation or decrease in use of a substance. All substance withdrawal syndromes are classified and diagnosed based on criteria published in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5). All withdrawal syndromes range in their ability to cause significant medical and/or psychiatric consequences. Alcohol withdrawal remains a medically serious syndrome that can occur within hours to days of decreased use and result in hallucinations, delirium, seizures, and death. Despite increasing research into the type, frequency, dose, and route of administration, benzodiazepines remain the first-line treatment in preventing alcohol withdrawal complications. Although typically not medically severe, opioid withdrawal is often associated with relapse even after successful detoxification. Opioid-agonist therapy, including methadone and buprenorphine, remains the treatment of choice for both opioid withdrawal and relapse prevention. Stimulant withdrawal from cocaine or amphetamines can cause significant psychiatric symptoms within minutes to hours of cessation and may require psychiatric hospitalization for suicidal ideation or attempts. There are no current medications approved by the Food and Drug Administration (FDA) for treatment of stimulant withdrawal. Cannabis withdrawal, although not medically dangerous, has recently been adopted as a discrete syndrome in the DSM-5. Its severity correlates significantly with the amount of cannabis used, functional impairment, and ability to achieve sustained remission. There are no current medications approved by the FDA for treatment of cannabis withdrawal.
This review contains 6 figures, 12 tables, and 100 references.
Key words: alcohol, amphetamine, benzodiazepines, buprenorphine, cannabis, clonidine, cocaine, dexmedetomidine, methadone, opioid, phenobarbital, stimulant, withdrawal
Treatment of Unhealthy Alcohol Use
By Stephen R Holt, MD, MSc; David A Fiellin, MDPurchase PDF
Treatment of Unhealthy Alcohol UsePurchase PDF
Unhealthy alcohol use represents the fifth leading cause of morbidity and mortality globally, and the first leading cause among persons 18 to 45 years of age. Despite the global impact of unhealthy alcohol use, the adoption of evidence-based treatments has been sluggish. Behavioral strategies for lower level drinking include the brief motivational interview, designed to be within the scope of any healthcare provider, and more specialist-driven approaches for those with alcohol use disorder (AUD) such as cognitive behavioral therapy and motivational enhancement therapy. Benzodiazepines remain the mainstay treatment for inpatient alcohol withdrawal treatment, whereas other medications have similar efficacy in managing patients in the outpatient setting with milder forms of withdrawal. For maintenance treatment of AUD, four FDA-approved medications exist, with efficacy in treating AUD, as well as several non–FDA-approved medications that have been found to be effective in promoting abstinence and reducing drinking. The use of medication to treat many patients with AUD falls within the scope of primary care providers.
This review contains 6 tables and 54 references.
Key Words: addiction, alcohol, counseling, drinking, pharmacotherapy, primary care, psychotherapy, relapse, treatment
Unhealthy Alcohol Use
By Joseph H. Donroe, MD, MPH ; Stephen R Holt, MD, MScPurchase PDF
Unhealthy Alcohol UsePurchase PDF
Unhealthy alcohol use refers to a spectrum of alcohol consumption ranging from at-risk drinking to alcohol use disorder. It is associated with both a high cost to society and to individuals. Globally, alcohol is a leading cause of death and disability, and despite the high prevalence of unhealthy alcohol use, diagnosis, and treatment of alcohol use disorder remains disproportionately low. Risk for unhealthy alcohol use and alcohol related harms is multifactorial and includes genetic factors, gender, age, socioeconomic status, cultural and societal norms, and policies regulating alcohol consumption among others. Excessive alcohol use is associated with a myriad of poor physical and mental health outcomes, and screening for unhealthy alcohol use is universally recommended and effective.
This review contains 1 figures, 2 tables, and 76 references.
Key Words: addiction, alcohol, cancer, diagnosis, drinking, liver disease, screening, stigma, use disorder
- Child Psychiatry
Attention-deficit/hyperactivity Disorder in Children and Adolescents
By Sergio Delgado, MDPurchase PDF
Attention-deficit/hyperactivity Disorder in Children and AdolescentsPurchase PDF
Attention-deficit/hyperactivity disorder (ADHD) is the most common and thoroughly researched neuropsychiatric disorder affecting children and adolescents. The prevalence of ADHD ranges from 8 to 12% in school-age children, and 70% of these individuals continue to meet DSM-5 criteria for the disorder in adolescence. ADHD is more commonly diagnosed in boys compared with girls. ADHD is chronic, with prominent symptoms and impairment in family, social, and academic functioning. ADHD is often associated with comorbid disorders, including disruptive, mood, and anxiety disorders, and can increase the risk of developing substance use disorders. The diagnosis of ADHD requires a comprehensive clinical assessment, including a detailed history, clinical interview, and collateral information, and is clinically established by review of symptoms and impairment and having established a developmental history of the symptoms. The biological underpinning of the disorder is supported by genetic, neuroimaging, neurochemistry, and neuropsychological data. Treatment should attend to developmental milestones of the child and include family and individual psychosocial interventions. Psychosocial interventions in combination with medication are helpful for ADHD and comorbid problems. Pharmacotherapy, including psychostimulants, noradrenergic agents, alpha agonists, and antidepressants, plays a fundamental role in the treatment and management of ADHD.
This review contains 2 figures, 9 tables, and 114 references.
Key words: attention, attention-deficit/hyperactivity disorder, comorbidity, hyperactivity, impulsivity, learning, nonstimulants, psychosocial, psychostimulants, treatment
Overview of Neurodevelopmental Disorders and Assessment of ChildrenPurchase PDF
Overview of Neurodevelopmental Disorders and Assessment of ChildrenPurchase PDF
Autism Spectrum Disorders and Their Clinical Management
By Ernest Pedapati, MD, MS, FAAP; Jacob Shaffer, BS, MD CandidatePurchase PDF
Autism Spectrum Disorders and Their Clinical ManagementPurchase PDF
Autism spectrum disorder (ASD) is a complex neurodevelopmental disorder marked by impairments in social behavior and difficulties with repetitive and restrictive behaviors. In 2012, the prevalence of ASD in the United States was estimated to be one in 68 among children age 8 years. Although the etiology of ASD is poorly understood, many researchers have identified genetic, epigenetic, and environmental factors likely involved in the disorder. In approximately 10% of cases, a definitive association with a specific genetic defect can be identified. A diagnosis of ASD is best performed through an interdisciplinary assessment and is based on diagnostic criteria. The DSM-5 criteria on the clinical features of ASD fall into two core domains: impaired social communication and interaction and restricted, repetitive behaviors, interests, or activities. Today, although no definitive “cure” for ASD exists, state-of-the-art therapies and learning environments, along with medications, have resulted in reducing disease burden and quality of life for individuals affected by ASD.
This review contains 3 figures, 2 tables, and 86 references.
Key words: autism spectrum disorders, developmental disorders, language speech delay, social communication
Oppositional Defiant Disorder and Its Clinical Management
By Reem Shafi, MBBS; Paul Croarkin, MDPurchase PDF
Oppositional Defiant Disorder and Its Clinical ManagementPurchase PDF
Oppositional defiant disorder (ODD) is a psychiatric disorder classified in the DSM-5 among disruptive, impulse control, and conduct disorder. The core features of ODD include a pervasive and impairing pattern of anger, irritability, inflexibility, defiance, malevolence, and aggression. Symptoms of ODD typically present during preschool. ODD can be a harbinger of conduct disorder. Isolated, transient symptoms of ODD are normal during development. Mood disorders, attention-deficit/hyperactivity disorder, and neurodevelopmental disorders are important considerations in differential diagnosis. However, ODD frequently co-occurs with other psychiatric diagnoses. Complex interactions with temperamental emotional dysregulation, family stress, early life stress, inconsistent parenting, and genetic and physiologic factors likely underlie the risk, pathophysiology, and prognosis of ODD. Unfortunately, these interactions and the neurobiological underpinnings of ODD are still poorly characterized. Although first-line treatments for ODD involve behavioral and psychosocial interventions, a thoughtful consideration of pharmacotherapy for co-occurring disorders and severe symptoms is an important component of treatment planning. Herein we review the epidemiology, etiology, pathophysiology, diagnostic evaluation, and treatment planning of ODD. Recent applicable controversies such as dimensional conceptualization of psychiatric disorders and the potential intersection of ODD and disruptive mood dysregulation disorder are also summarized.
This review contains 5 figures, 4 tables, and 44 references.
Key words: aggression, attention-deficit/hyperactivity disorder, conduct disorder, defiance, disruptive behaviors, disruptive mood dysregulation disorder, DSM-5,irritability, oppositional defiant disorder, parent management training
By Jodi Tate, MD; Kelly Vinquist, PhDPurchase PDF
Intellectual DisabilityPurchase PDF
Individuals with an intellectual disability are one of the most underserved populations in the United States. They have higher rates of medical and psychiatric comorbidity when compared to the general population and face considerable healthcare disparity. Challenging behavior such as physical or verbal aggression is the most common reason why this population interfaces with the mental healthcare system. Understanding and correctly diagnosing the underlying etiology of challenging behaviors requires comprehensive evaluations along with awareness of the key variables that contribute to the occurrence of these behaviors. The differential diagnosis of challenging behavior is wide and includes mental illness, medical illness, pain, side effects from medications, behavioral phenotype of underlying syndrome, behavioral/functional, deficit of skills, and/or developmentally appropriate behavior.
This review contains 1 figure, 6 tables and 83 references
Key words: behavioral phenotype, challenging behaviors, etiology, intellectual disability, mental retardation, mental illness, psychiatric disorders
Conduct Disorder and Its Clinical Management
By Bianca Patel, BA; Drew Barzman, MDPurchase PDF
Conduct Disorder and Its Clinical ManagementPurchase PDF
Conduct disorder (CD), a psychiatric condition that is prevalent in some child and adolescent populations, is defined by the DSM-5 as a repetitive and persistent pattern of behavior in which the rights of others and age-appropriate cultural norms are violated. DSM-5 subtypes include childhood-onset, adolescent-onset, and callous-unemotional presentations. The development of CD is affected by gender, age at onset, environmental factors, and genetic factors. Overall, it has been difficult to identify causative factors because there is such a diverse variety of factors and comorbidities involved, although studies to define specific genetic, physiologic, and neurologic links to CD are ongoing. Common comorbidities in CD include oppositional defiant disorder, attention-deficit/hyperactivity disorder (ADHD), major depressive disorder, bipolar disorder, dysthymia, and substance abuse. The most successful treatment involves a multisystemic approach involving medication, family therapy, educational therapy, and parenting skills. Overall, early prevention of CD through treatment is key because the prognosis is poor and can be associated with the development of more severe comorbidities.
This review contains 3 tables, and 58 references.
Key words: antisocial behavior behavioral issues, ADHD comorbidities, child mental disorders, conduct disorder
- Cognitive Disorders
By Jeanne Maglione, MD, PhD; Dilip Jeste, MDPurchase PDF
Successful AgingPurchase PDF
The number of older adults in our society is increasing rapidly. Aging is complex and may occur at varying rates across multiple domains, including biological aging, cognitive aging, and emotional aging. Age-related medical conditions are now among the leading causes of morbidity and mortality among older adults, making healthy aging a major public health priority. Successful aging encompasses more than longevity, medical health, or freedom from disability. It can be viewed as a multidimensional construct including minimization of disability and medical illness combined with maximization of physical, cognitive, emotional, and social functioning. We review the current literature regarding successful aging. We also discuss strategies to improve the likelihood of successful aging and several key advances, such as definitions of successful aging in different populations, neuroplasticity of aging, wisdom as an empirical construct, the concept of a good (or successful) death, and the development of age-friendly communities.
This review contains 3 figures, 5 tables, and 53 references.
Key words: aging, elderly, older adult, successful aging, successful aging interventions
Subjective Cognitive Impairment and Mild Cognitive Impairment (predementias)
By Shashank Beesam, MD; Eric Marin, MD; George Grossberg, MDPurchase PDF
Subjective Cognitive Impairment and Mild Cognitive Impairment (predementias)Purchase PDF
Alzheimer disease is thought to have an insidious progression, with asymptomatic brain changes occurring decades prior to formal diagnosis. In recent years, efforts have been made to identify and characterize these changes into a spectrum beginning with subjective cognitive decline through the development of major neurocognitive disorder. Through this process, progress has been made into the predictive factors, prevention, and treatment modalities for the various stages of cognitive decline. In addition to pharmacologic therapies, studies have shown the value in physical, mental, social, and spiritual activity combined with support from physicians, family, and caregivers. Furthermore, individualized care, open and honest physician-patient dialogue, and emphasis on lifestyle modifications have been shown to achieve optimal quality of life and may also decrease the rate of cognitive decline.
This review contains 5 figures, 5 tables, and 36 references.
Key words: age-related cognitive decline, Alzheimer disease, major neurocognitive disorder, mild cognitive impairment, mild neurocognitive disorder, senior moment, subjective cognitive impairment
Major Neurocognitive Disorders
By Rajesh R Tampi, MD, MS, DFAPA; Deena J Tampi, MSN, MBA-HCA, RNPurchase PDF
Major Neurocognitive DisordersPurchase PDF
Major neurocognitive disorder is the most common neurodegenerative condition in the world and the leading cause of dependence and disability among older adults worldwide. There are numerous etiologies for major neurocognitive disorder, of which Alzheimer disease (AD) is the most common. Available evidence indicates that the risk factors for major neurocognitive disorder include older age, female sex, lower educational attainment, obesity, and vascular risk factors, including smoking, hypertension, diabetes mellitus, and hyperlipidemia. Certain etiologies for major neurocognitive disorder are heritable, especially those due to AD and frontotemporal lobar degeneration. The pathophysiologic changes associated with the various etiologies of major neurocognitive disorder include neuronal loss, senile plaques, neurofibrillary tangles, vascular pathology, and α-synuclein neuronal inclusions. Major neurocognitive disorder remains a clinical diagnosis with a thorough history, appropriate laboratory tests, and standardized rating scales assisting in determining the etiology and severity of the condition. In older adults, major neurocognitive disorder must be differentiated from depression and delirium as these three conditions may have similar clinical presentations or may coexist. Current data indicate that approximately a third of the cases of major neurocognitive disorder, especially those due to AD, may be prevented by controlling potentially modifiable risk factors, including diabetes, depression, smoking, physical inactivity, midlife hypertension, midlife obesity, and low educational attainment. Currently, the only Food and Drug Administration–approved medications are acetylcholinesterase inhibitors and memantine for use in major neurocognitive disorder due to AD and rivastigmine (an acetylcholinesterase inhibitor) for major neurocognitive disorder due to Parkinson disease.
Key words: acetylcholinesterase inhibitors, Alzheimer disease, amyloid precursor protein, frontotemporal lobar degeneration, Lewy body disease, major neurocognitive disorder, memantine, Parkinson disease, tau proteins, vascular disease
Epilepsy and Related Disorders
By Barbara Dworetzky, MD; Jong Woo Lee, MD, PhDPurchase PDF
Epilepsy and Related DisordersPurchase PDF
Epilepsy is a chronic disorder of the brain characterized by recurrent unprovoked seizures. A seizure is a sudden change in behavior that is accompanied by electrical discharges in the brain. Many patients presenting with a first-ever seizure are surprised to find that it is a very common event. A reversible or avoidable seizure precipitant, such as alcohol, argues against underlying epilepsy and therefore against treatment with medication. This chapter discusses the epidemiology, etiology, and classification of epilepsy and provides detailed descriptions of neonatal syndromes, syndromes of infancy and early childhood, and syndromes of late childhood and adolescence. The pathophysiology, diagnosis, and differential diagnosis are described, as are syncope, migraine, and psychogenic nonepileptic seizures. Two case histories are provided, as are sections on treatment (polytherapy, brand-name versus generic drugs, surgery, stimulation therapy, dietary treatments), complications of epilepsy and related disorders, prognosis, and quality measures. Special topics discussed are women?s issues and the elderly. Figures illustrate a left midtemporal epileptic discharge, wave activity during drowsiness, cortical dysplasias, convulsive syncope, rhythmic theta activity, right hippocamal sclerosis, and right temporal hypometabolism. Tables describe international classifications of epileptic seizures and of epilepsies, epilepsy syndromes and related seizure disorders, differential diagnosis of seizure, differentiating epileptic versus nonepileptic seizures, antiepileptic drugs, status epilepticus protocol for treatment, when to consider referral to a specialist, and quality measures in epilepsy. This chapter contains 111 references.
Encephalopathy and Delirium
By Alliya S. Qazi, MD; Juliana Barr, MD, FCCMPurchase PDF
Encephalopathy and DeliriumPurchase PDF
Delirium occurs commonly in critically ill patients. ICU delirium is associated with increased short-term and long-term mortality, increased ICU length of stay, and long-term cognitive deficits in these patients. There are significant health-care costs associated with ICU delirium. Delirium is often overlooked in patients when assessed by clinicians based on clinical judgment alone. The use of a validated delirium assessment tool increases delirium detection rates in patients. ICU delirium is a multifactorial process. Nonmodifiable risk factors include age, dementia, prior coma, emergency surgery or trauma, and a high severity of illness. Modifiable risk factors include benzodiazepine use and blood transfusions. There is no evidence to support the use of any pharmacologic agent for either the prevention or treatment of ICU delirium. Antipsychotics should only be used for symptom management in ICU patients with delirium, and then discontinued when no longer needed. The mainstay of delirium management should be a multi-component, non-pharmacologic strategy aimed at minimizing risk factors. One such multimodal strategy, the ABCDEF Bundle, can significantly decrease the incidence of ICU delirium. Additional research is needed to better understand the pathophysiology and management of ICU delirium.
This review contains 5 figures, 5 tables, and 50 references.
Keywords: Delirium, Encephalopathy, Intensive Care, Outcomes, ABCDEF Bundle, ICU Liberation.
- Dissociative Disorders
Dissociative Disorders and Their Clinical Management Part One: Dissociative Amnesia (including Its Variant Dissociative Fugue)
By Angelica Staniloiu, MD, PhD; Hans Markowitsch, PhDPurchase PDF
Dissociative Disorders and Their Clinical Management Part One: Dissociative Amnesia (including Its Variant Dissociative Fugue)Purchase PDF
Dissociative disorders are heterogeneous with respect to clinical features, course, antecedents and treatment. Among them, dissociative amnesia occupies a special place, at times encroaching on the borders between neurology and psychiatry. Herein we describe dissociative amnesia according to the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders and outline data on its epidemiology, neurobiology, neuroimaging, clinical and differential diagnosis, neuropsychology, comorbidities, prognosis, treatment and rehabilitation. To enable a neuroscientific approach to its diagnosis, we outline the memory division into short-term and long-term memory, elaborating on the content-based classification of the long-term memory systems. Dissociative amnesia most commonly manifests itself in its retrograde variants (including dissociative fugue), but anterograde variants can also occur. Dissociative amnesia may be overlooked when it occurs on a background of mixed antecedents and comorbidities. Comprehensive neuropsychological assessment – including tests tapping on all memory systems and symptom validity tests – is still insufficiently integrated in the clinical practice, although it could aid in securing an accurate diagnosis, especially in cases with mixed antecedents or concomitant forensic or litigation backgrounds. Presently there is a paucity of treatment and rehabilitation methods for dissociative amnesia. Developing research evidence-based consensus guidelines for diagnosis and treatment is an essential goal.
This review contains 6 figures, 7 tables, and 60 references.
Key Words : consciousness, episodic-autobiographical memory, mnestic block syndrome, neuroimaging, serial-parallel-independent model, personal identity, stressful life events, malingering, trauma, feigning
By Brendan Carroll, MD; Donald W. Black, MD; Francisco Appiani, MD; Jo Ellen Wilson, MD; Rebecca Miesle, OMS-IIIPurchase PDF
Catatonia is a syndrome, not a discrete illness, and was first recognized by Kahlbaum in the 19th century. Catatonia is underdiagnosed and often goes unrecognized despite its clinical significance and treatment implications. The syndrome’s motor symptoms include muteness, rigidity, and stupor. Catatonia has been associated with various psychiatric, medical, and neurologic disorders and is no longer only considered a subtype of schizophrenia. There is no known etiology, but its rapid improvement with benzodiazepines suggests that γ-aminobutyric acid (GABA), an inhibitory neurotransmitter, is involved. Patients displaying catatonic symptoms should have a comprehensive evaluation to rule out medical and neurologic causes and to assess hydration and nutritional status. Patients can have significant nursing care needs, and some might need tube feedings. Benzodiazepines are the first-line treatment, with electroconvulsive therapy reserved for those who fail to respond or have an inadequate response to benzodiazepines. Psychiatrists and other clinicians should understand the diagnosis and treatment of catatonia.
This review contains 4 tables and 52 references
Key words: bipolar disorder, catatonia, delirium, GABA, glutamate, major depressive disorder, schizophrenia
- Mood and Anxiety Disorders
Neurobiology of Anxiety Disorders
By Pooja Palkar, MBBS; Eric Hollander, MDPurchase PDF
Neurobiology of Anxiety DisordersPurchase PDF
In recent years, advances in the fields of neuroimaging and experimental psychology increased our understanding of the basic mechanisms of classical conditioning and learning, contributing to our knowledge of the neurobiology of anxiety disorders. Research has shown that the amygdala is the cornerstone of fear circuitry and that abnormalities in amygdala pathways can affect the acquisition and expression of fear conditioning. Activation of the amygdala in response to disorder-relevant stimuli has been observed in anxiety disorders. The roles of the hippocampus, nucleus accumbens, periaqueductal gray, and insular and medial prefrontal cortices in response to fear have been identified as well. Neurotransmitters such as serotonin, dopamine, γ-aminobutyric acid, glutamate, and some neurosteroids play an important part in the neurobiology of anxiety disorders. Neuropeptides such as oxytocin, neuropeptide Y, galanin, and cholecystokinin have been shown to modulate stress response. Drugs such as N-methyl-d-aspartate (NMDA) antagonists and blockers of voltage-gated calcium channels in the amygdala are anxiolytic. Fear extinction, which entails new learning of fear inhibition, is the mechanism of effective antianxiety treatments such as d-cycloserine, a partial NMDA agonist. Extinction is thought to occur by the medial prefrontal cortex, which inhibits the lateral amygdala under hippocampal modulation. Harnessing extinction to delink neutral stimuli from aversive responses is an important goal of the psychotherapy and pharmacotherapy of anxiety disorders. Discovery of the role of microRNAs in the etiology of anxiety disorders and their possible utility as targets to treat these disorders is fascinating. In this review, we discuss the neurobiology of anxiety disorders, which will help us better manage them clinically.
Key words: amygdala, anxiety disorders, neurobiology, fear conditioning, neurocircuitry, neurotransmitters, neuropeptides, neurosteroids, endogenous opioids.
Overview of Anxiety Disorders
By Jon E Grant, JD, MD, MPHPurchase PDF
Overview of Anxiety DisordersPurchase PDF
Anxiety disorders are the most common psychiatric disorders among adults in the United States. Although anxiety disorders generally result in significant psychosocial impairment, most adults do not seek treatment until many years after the onset of the anxiety disorder. The treatment literature for anxiety disorder has grown tremendously since the 1980s, and both psychotherapy and medications may prove beneficial for people with anxiety disorders. This review presents a general overview of the anxiety disorders.
This review contains 7 tables, and 33 references.
Key words: agoraphobia, anxiety disorder, generalized anxiety disorder, panic disorder, separation anxiety disorder, social anxiety disorder, specific phobia, treatment of anxiety
Clinical Management of Anxiety Disorders
By Shona Vas, PhD; Pooja N Dave, PhDPurchase PDF
Clinical Management of Anxiety DisordersPurchase PDF
Anxiety disorders are characterized by excessive fear and anxiety accompanied by associated behavioral disturbances that cause significant impairment in social and occupational functioning. Anxiety is a complex mood state that involves physiologic, cognitive, and behavioral components. This review describes the five anxiety disorders most commonly diagnosed in adults: social anxiety disorder, panic disorder, agoraphobia, generalized anxiety disorder, and specific phobia. Diagnostic criteria for these disorders are presented along with empirically supported psychological and pharmacologic treatment approaches. Decades of evidence have indicated that for anxiety disorders of mild to moderate severity, cognitive-behavioral therapy (CBT) should be first-line treatment. CBT interventions for anxiety, including psychoeducation, cognitive restructuring, exposure, applied relaxation/breathing retraining, and skills training, are presented with descriptions of how they may be adapted to particular diagnoses, along with data for their efficacy. Data suggest that selective serotonin and norepinephrine reuptake inhibitors are pharmacologic treatments of choice for anxiety and may be used in combination with CBT for moderate to severe symptoms. d-Cycloserine is an emerging treatment that may enhance outcomes in anxiety disorders by optimizing exposure therapy through the facilitation of fear extinction.
This review contains 7 figures, 12 tables, and 105 references.
Key words: agoraphobia, anxiety, generalized anxiety disorder, panic disorder, phobias, social anxiety disorder
Depressive Disorders: Update on Diagnosis, Etiology, and Treatment
By Isabelle E. Bauer, PhD; Antonio L Teixeira, MD, PhD; Marsal Sanches, MD, PhD; Jair C. Soares, MDPurchase PDF
Depressive Disorders: Update on Diagnosis, Etiology, and TreatmentPurchase PDF
This review discusses the changes in the diagnostic criteria for depressive disorders as outlined in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), and recent findings exploring the etiology of and treatment strategies for these disorders. Depressive disorders are typically characterized by depression in the absence of a lifetime history of mania or hypomania. New developments in the DSM-5 include the recognition of new types of depressive disorders, such as disruptive mood dysregulation disorder, persistent depressive disorder, premenstrual dysphoric disorder, and the addition of catatonic features as a specifier for persistent depressive disorder. These diagnostic changes have important implications for the prognosis and treatment of this condition. A thorough understanding of both the clinical phenotype and the biosignature of these conditions is essential to provide individualized, long-term, effective treatments to affected individuals.
This review contains 1 table and 52 references
Key words: brain volumes, depressive disorders, DSM-5, hormones, inflammation, neuropeptides, somatic therapy, stress
Clinical Management of Depressive Disorders
By Jon E. Grant, JD, MD, MPH; Sanjay Gupta, MDPurchase PDF
Clinical Management of Depressive DisordersPurchase PDF
Neurobiology of Mood Disorders
By Genoveva Uzunova, MD, PhD; Vera Nezgovorova, MD; Danya Schlussel, MS; Eric Hollander, MDPurchase PDF
Neurobiology of Mood DisordersPurchase PDF
Mood disorders (major depressive disorders [MDDs] and bipolar disorders [BDs]) are common psychiatric conditions and major causes of morbidity and mortality worldwide. Their neurobiology is extensively studied, and major advances have been made in understanding the neuroanatomic, neurochemical, synaptic plasticity, and genetic correlates. In this review, we discuss the major neuroanatomic regions in the brain affected in mood disorders and brain structural and functional alterations, the main hypotheses for the neurobiology, the major neurotransmitters and neuromodulators implicated, the synaptic plasticity changes, the role of stress and the hypothalamic-pituitary-adrenal axis, the importance of circadian rhythms, and the role of genetics. We discuss differences in the neurobiology between MDDs and BDs and connect the knowledge of neurobiology to therapeutics. We discuss the main classes of medications, such as antidepressants for treatment of MDD and mood-stabilizing drugs for treatment of BD, and neuromodulation therapies such as transcranial magnetic stimulation. We point to unanswered questions and future directions, such as elucidation of the role of atypical neurotransmitters in mood disorders, the need for better understanding of the genetics and interactions between the immune and central nervous systems, and the development of biomarkers and personalized therapeutics based on the neurobiology. Notably, there are discrepancies in the current scientific knowledge and many unanswered questions in the neurobiology due to the different ages of patients, disease stage, presence of medications, and other comorbidities. It is notable, however, that mood disorders have a clearly established biological basis with alterations in the immune and central nervous systems that affect synaptic plasticity, neural circuits, and larger-scale brain networks and communicate with the autonomic nervous system.
This review contains 5 figures, 4 tables and 62 references
Key words: antidepressant, bipolar disorder, epigenetics, hypothalamic-pituitary-adrenal axis, immune system, limbic system, major depressive disorder, mood stabilizer, neurotransmitter, synaptic plasticity, transcranial magnetic stimulation
Diagnosis, Etiology, and Treatment of Premenstrual Dysphoric Disorder
By Edwin Raffi, MD, MPH; Marlene P. Freeman, MDPurchase PDF
Diagnosis, Etiology, and Treatment of Premenstrual Dysphoric DisorderPurchase PDF
Premenstrual dysphoric disorder (PMDD) was recognized as an official psychiatric diagnosis among depressive disorders in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The exact etiology of PMDD is not yet fully understood, and it is a topic of current research. The hope is that learning more about PMDD can lead to improved treatment modalities for this disorder and better understanding of other related disorders (such as premenstrual mood exacerbation and postpartum- or menopause-related mood disorders). Often misdiagnosed and likely underdiagnosed, PMDD has a 12-month prevalence that ranges from 1.8 to 5.8% for women who menstruate. Mental health providers who treat women of reproductive age should be familiar with the diagnostic criteria, related differential diagnosis, and available treatment modalities for PMDD.
This review contains 5 figures, 5 tables and 59 references
Key words: mood disorder, premenstrual dysphoric disorder, premenstrual exacerbation, premenstrual syndrome, reproductive mental health, reproductive psychiatry, women’s mental health
Obsessive-compulsive Disorder (introduction)
By Dan Stein, MD, PhD; Eileen Thomas, MD; Christine Lochner, PhDPurchase PDF
Obsessive-compulsive Disorder (introduction)Purchase PDF
A hallmark feature of OCD is the presence of obsessions and/or compulsions. The subtyping of OCD has been expanded to allow for a detailed assessment of individuals and their disorder, including insight and tic-related specifiers. Although some individuals with OCD rationalize their behaviors as useful, they are time consuming and cause marked distress and/or functional impairment.
This review contains 1 table, and 31 references.
Key words: diagnostic and statistical manual, obsessive-compulsive disorder
By Dan Stein, MD, PhD; Eileen Thomas, MD; Christine Lochner, PhDPurchase PDF
Hoarding DisorderPurchase PDF
Hoarding disorder is characterized by an obsessive need to acquire, collect, or keep possessions and difficulty in organizing and discarding, resulting in accumulation of clutter, which elicits great concern from family and friends. Functioning is usually impaired in a variety of domains. Obsessive-compulsive disorder is the disorder most closely associated with hoarding. Overvalued ideation regarding the value or usefulness of possessions may make it impossible for individuals to discard items.
This review contains 1 table, and 22 references.
Key words: clutter, diagnostic and statistical manual, etiology, hoarding, obsessive-compulsive and related disorder
Body Dysmorphic Disorder
By Dan Stein, MD, PhD; Eileen Thomas, MD; Christine Lochner, PhDPurchase PDF
Body Dysmorphic DisorderPurchase PDF
Body dysmorphic disorder requires obsessional thoughts regarding a perceived defect in appearance and/or compulsive behavior that develop in response to those thoughts. Individuals experience clinically significant impairment because of their appearance concerns. Body dysmorphic disorder and obsessive-compulsive disorder have many similarities, including phenomenologic features, comorbidities, and underlying pathophysiology. Insight into the excessiveness or irrationality of their beliefs varies from good to delusional. Many individuals with body dysmorphic disorder present with comorbid suicidal ideation and substance use disorders.
This review contains 1 table, and 30 references.
Key words: body dysmorphic disorder, diagnostic and statistical manual, obsessive-compulsive and related disorder
By Dan Stein, MD, PhD; Eileen Thomas, MD; Christine Lochner, PhDPurchase PDF
Excoriation disorder is characterized by the recurrent, compulsive picking of skin, leading to skin lesions. A growing body of evidence emphasizes its prevalence and possible disabling nature, including medical complications such as localized infections and septicemia. Neurocognitive data support the idea that individuals with this disorder have difficulty inhibiting motor behaviors. Excoriation disorder is often considered a chronic disorder, fluctuating in intensity and severity. Important differentials include the use of stimulant drugs and dermatologic conditions, such as scabies.
This review contains 1 table, and 16 references.
Key words: diagnostic and statistical manual, excoriation, obsessive-compulsive and related disorder, skin picking
By Dan Stein, MD, PhD; Eileen Thomas, MD; Christine Lochner, PhDPurchase PDF
Trichotillomania (hair pulling disorder [HPD]) is a common disorder affecting mostly women that is often underreported and underrecognized. This condition involves repetitive hair pulling resulting in hair loss with repeated unsuccessful attempts to control or stop the pulling behavior. Individuals usually attempt to conceal or camouflage the hair loss. Clinical phenomenology, neurobiology, and genetic underpinning suggest associations between obsessive-compulsive disorder and HPD.
This review contains 1 table, and 19 references.
Key words: hair loss, hair pulling, obsessive-compulsive and related disorder, trichotillomania
Clinical Management of Obsessive-compulsive and Related Disorders
By Samuel R Chamberlain, MB/BChir, PhD, MRCPsychPurchase PDF
Clinical Management of Obsessive-compulsive and Related DisordersPurchase PDF
Obsessive-compulsive and related disorders (OCRDs) now have their own category in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition. Disorders currently classified as OCRDs are obsessive-compulsive disorder, trichotillomania (hair pulling disorder), excoriation (skin picking) disorder, hoarding disorder, and body dysmorphic disorder. Collectively, the OCRDs are prevalent, cause considerable functional impairment, and are often overlooked by clinicians. This review surveys current definitions and diagnosis of OCRDs, highlighting recommended assessment tools, differential diagnoses, and medical issues. The heritability of OCRDs is examined, based on available twin data, along with implicated genetic factors. Neurobiological understanding of OCRDs is outlined, focusing on dysregulation of habit generation and top-down response control corticostriatal pathways. The review then highlights evidence-based treatments for OCRDs, which differ considerably between individual disorders. Treatment guidance includes descriptions of target medication doses and therapy content. Lastly, limitations in the current knowledge base for OCRDs are reviewed, with implications for future research directions.
This review contains 1 figure, 7 tables, and 40 references.
Key words: compulsivity, dopamine, glutamate, impulsivity, screening for OCD, serotonin
Management of Depression, Part 1: Identification and Diagnosis
By Michael Banov, MDPurchase PDF
Management of Depression, Part 1: Identification and DiagnosisPurchase PDF
Clinical depression is a commonly occurring and profoundly disabling condition that affects approximately 4%, or nearly 350 million people, worldwide. Depression has been identified as the world’s leading cause of disability and a major contributor to overall global burden of disease. In the United States alone, estimates of economic burden are greater than 200 billion dollars, including costs of direct medical care, suicide-related mortality, and lost work productivity. Managing depression is challenging due to the marked variability in biological contributors, the heterogeneity of the illness, psychosocial history, current stresses exacerbating the condition, medical and psychiatric co-occurring conditions, lifestyle, and motivation and willingness to accept and engage in treatment recommendations. This review discusses diagnosis, depression screening and workup, neuroimaging, differentiation among depression types, patient safety, and treatment initiation in patients with depression. Tables list DSM-5 versus ICD-10 classification of depression and DSM-5 updates with respect to depression.
This review contains 5 tables and 60 references
Key words: bipolar depression, clinical depression, depression, depression screening, psychiatric neuroimaging, unipolar depression
Management of Depression, Part 2: Treatment Options
By Michael Banov, MDPurchase PDF
Management of Depression, Part 2: Treatment OptionsPurchase PDF
Clinical depression is a commonly occurring and profoundly disabling condition that affects approximately 4%, or nearly 350 million people, worldwide according to the World Health Organization. Managing depression is challenging due to the marked variability in biological contributors, the heterogeneity of the illness, psychosocial history, current stresses exacerbating the condition, medical and psychiatric co-occurring conditions, lifestyle, and motivation and willingness to accept and engage in treatment recommendations. Mental health professionals such as master-level counselors, psychologists, or psychiatrists are specially trained to identify and treat depression; however, a significant amount of depression presents in primary care medical settings. This review covers treatment of depression with psychotherapy, complementary and alternative medicine (CAM), and antidepressant medication, as well as treatment course and long-term depression treatment. Tables list CAM depression treatments, nonnutraceutical CAM therapies, managing antidepressant side effects, tricyclic antidepressants, serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, norepinephrine dopamine reuptake inhibitor, alpha2 antagonists, serotonin-2 antagonist/reuptake inhibitors, monoamine oxidase inhibitors, food restrictions with monoamine oxidase inhibitors, managing partial response/treatment-resistant depression, and serotonin receptor modulators.
This review contains 15 tables and 98 references
Key words: antidepressant medication, clinical depression, depression, monoamine oxidase inhibitors, nonpharmacologic depression treatment, omega-3 fatty acids, S-adenosylmethionine, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, St. John’s wort, tricyclic antidepressants
Bipolar Disorders and Their Clinical Management, Part I: Epidemiology, Etiology, Genetics, and Neurobiology
By Vladimir Maletic, MD; Bernadette DeMuri-Maletic, MDPurchase PDF
Bipolar Disorders and Their Clinical Management, Part I: Epidemiology, Etiology, Genetics, and NeurobiologyPurchase PDF
The concept of bipolar disorders has undergone a substantial evolution over the course of the past two decades. Emerging scientific research no longer supports the notion of bipolar disorder as a discrete neurobiologic entity. Most likely, there are a number of different biotypes with similar phenotypical manifestations. Advancements in genetic research suggest that bipolar disorders have a polygenetic pattern of inheritance, sharing common genetic underpinnings with a number of other psychiatric disorders, including schizophrenia, autistic spectrum disorder, and major depressive disorder. Contemporary etiological theories are discussed in some detail, inclusive of the role of immune disturbances, oxidative stress, and changes in neuroplasticity and neurotransmission, which underpin functional and structural brain changes associated with bipolar disorders. Contemporary epidemiologic research and understanding of disease evolution are discussed from the perspective of its clinical relevance. Our review provides a succinct summary of relevant literature.
This review contains 4 figures, 2 tables, and 80 references.
Key Words: bipolar disorders, endocrine disturbances, epidemiology, genetics, glia, immunity, neurobiology, neuroplasticity, neurotransmitters
Bipolar Disorders and Their Clinical Management, Part II: Diagnosis, Differential Diagnosis, and Treatment
By Bernadette DeMuri-Maletic, MD; Vladimir Maletic, MD, MSPurchase PDF
Bipolar Disorders and Their Clinical Management, Part II: Diagnosis, Differential Diagnosis, and TreatmentPurchase PDF
Bipolar disorder is a biologically and phenotypically diverse disorder and its diagnosis and treatment provides a significant challenge to even the most seasoned clinician. We provide an update on the diagnosis and differential diagnosis of bipolar disorder, reflecting recent changes in DSM-5. Our review provides a succinct summary of the treatment literature, encompassing pharmacologic and psychosocial interventions for bipolar depression, mania/hypomania, mixed states, and prevention of disease recurrence. We provide a brief critical review of emerging treatment modalities, including those used in treatment resistance. Challenges involved in maintaining adherence are further discussed. Additionally, we review common treatment adverse effects and provide recommendations for proper side effect monitoring. There is evidence of significant functional impairment in patients with bipolar disorder and we conclude with a discussion of the impact of impairment on prognosis and quality of life.
This review contains 7 tables and 45 references.
Key Words: bipolar disorders, differential diagnosis, maintenance pharmacotherapy, prognosis, psychosocial interventions, treatment, quality of life
ECT: Physiology, Indications, and Treatment
By Max Fink, MDPurchase PDF
ECT: Physiology, Indications, and TreatmentPurchase PDF
Inducing grand mal seizures (electroshock, electroconvulsive therapy) developed as an effective treatment to alleviate the psychosis of dementia praecox. Clinicians quickly recognized that seizures also relieved depressed moods, suicide risk, catatonia, manic excitement, and delirium. It is an unheralded, often stigmatized, medical achievement. Seizures may be induced chemically or with electric or magnetic currents. Grand mal seizures must be repeated for persistent benefits. Not all seizures are equally effective. Effective seizures are marked by bilateral electroencephalographic brain wave changes and neuroendocrine discharges from hypothalamic-pituitary glands. Treatments are remarkably safe, with zero mortality. Immediate effects on memory are common but are almost always transient. They are not a practical deterrent to the treatments, although they are widely cited to reject its use. The stigmatization of induced seizures that places it as a “last resort” therapy is wasteful and unethical. It offers a remarkable opportunity for advancement in neuroscience.
This review contains 4 figures, 3 tables, and 90 references.
Key words: anesthesia, bipolar disorder, catatonia, delirium, electroconvulsive therapy, electroencephalography, major depression, melancholia, neuroendocrine, seizures
By Scott Aaronson, MD; Paul Croarkin, DO, MSPurchase PDF
Neurostimulation modalities in psychiatric practice and research efforts use magnetic and electric fields to modulate neuronal functioning. Physicians have used these modalities since ancient history, but most modern brain stimulation treatments developed after the inception electroconvulsive therapy in 1937. Noninvasive brain stimulation generally refers to treatments that do not require surgery, such as electroconvulsive therapy, repetitive transcranial magnetic stimulation, and transcranial current stimulation. Conversely, deep brain stimulation and vagal nerve stimulation are the two most researched invasive brain stimulation modalities for psychiatric disorders. Treatment with repetitive transcranial magnetic stimulation has been shown to be effective for the treatment of resistant major depressive disorders but is less rapid acting and may be optimal for a different patient population as compared to electroconvulsive therapy. Research focused on transcranial direct current stimulation continues to expand, but its role in clinical psychiatric practice is currently not well defined. Despite mixed and, in some cases, disappointing results, invasive brain stimulation techniques such as deep brain stimulation and vagal nerve stimulation will likely continue to have an important role for certain treatment-resistant populations in psychiatric practice. This review examines the development, basic physiologic mechanisms, and evidence base of neurostimulation modalities in psychiatry.
This review contains 4 figures, 6 tables and 38 references
Key Words: deep brain stimulation, invasive, neurostimulation, noninvasive, transcranial direct current stimulation, transcranial electrical stimulation, transcranial magnetic stimulation, treatment-resistant depression, vagal nerve stimulation
- Personality Disorders
Overview of the Personality Disorders
By Donald W. Black, MDPurchase PDF
Overview of the Personality DisordersPurchase PDF
Part 1: Borderline Personality Disorder and Its Clinical Features
By Robert Biskin, MDCM, MSc.; Joel Paris, MDPurchase PDF
Part 1: Borderline Personality Disorder and Its Clinical FeaturesPurchase PDF
Borderline personality disorder (BPD) is routinely encountered in all clinical settings and has been stigmatized and perceived as a difficult disorder to manage. Over the past 25 years, significant gains in our understanding of the diagnosis, treatment, and outcomes of the disorder have helped improve the lives of these patients. BPD is now understood to begin in adolescence and early adulthood, with a generally positive course and reductions in symptoms of self-harm and suicidality within several years of diagnosis. BPD is best understood as developing through an interaction between genetic and environmental factors. No clear biological features have been consistently identified yet, and similarly, no clear psychosocial factor, including childhood adversity or sexual abuse, is causative for BPD. Clearly separating BPD from other disorders, particularly bipolar disorder, is an important consideration and required to ensure proper care. Comorbid disorders, including other personality disorder, are frequent problems that partially reflect a challenge with the current diagnostic system that has not yet been resolved. Although the symptomatic outcome of patients with BPD is very good, functional outcomes, such as holding work and relationships, is more challenging for many patients, and suicide remains a risk in patients with this disorder.
This review contains 2 figures, 4 tables, and 102 references.
Key words: borderline personality disorder, outcome, personality disorder, self-harm, suicide
Part 2: Borderline Personality Disorder and Its Clinical Management
By Robert Biskin, MDCM, MSc.; Joel Paris, MDPurchase PDF
Part 2: Borderline Personality Disorder and Its Clinical ManagementPurchase PDF
The treatment of patients with borderline personality disorder (BPD) has changed significantly over the past 25 years. The previous therapeutic pessimism about BPD treatment outcomes has become more optimistic with the development of a variety of specialized psychotherapies that have been shown to reduce self-harm, suicidality, and health service use as well as improve overall psychopathology. Dialectical behavior therapy was the first evidence-supported treatment, but it has been joined by mentalization-based psychotherapy and a variety of other treatments. Several common factors, including structured treatment approach, are likely important in the effectiveness of these treatments compared with unstructured comparators. Pharmacotherapy serves a more limited role in the treatment of BPD due to many methodological issues in the research and a lack of replication of studies. Judicious and rational use of pharmacotherapy is discussed, as well as suggestions for improving accessibility to specialized psychotherapies through the development of stepped care models. Improving access to care for patients with BPD, throughout all age groups, remains an important next step.
This review contains 2 figures, 1 table, and 47 references.
Key words: borderline personality disorder, dialectical behavior therapy, mentalization-based treatment, personality disorder, pharmacotherapy, psychotherapy, self-harm
Antisocial Personality Disorder and Its Clinical Management
By Donald W. Black, MDPurchase PDF
Antisocial Personality Disorder and Its Clinical ManagementPurchase PDF
Antisocial personality disorder (ASPD) is characterized by irresponsibility, aggression, criminality, and, in some, a lack of conscience. Recognized for over 200 years, ASPD is associated with domestic violence, psychiatric comorbidity, substance abuse, and excess health care use. ASPD is highly prevalent, and most affected individuals are men. ASPD has its onset in childhood or adolescence, when it may be diagnosed as a disruptive behavior disorder or conduct disorder. Not diagnosed until age 18, ASPD peaks in severity in the late teens or early 20s. It is lifelong for most persons, although the trend is toward improvement in those individuals with an adolescent onset and a prominent antisocial lifestyle. Those who do best have milder syndromes, are married/partnered, have stable jobs, and are older. ASPD is thought to result from a combination of genetic and environmental factors. Some antisocial persons have shown functional abnormalities in limbic structures and the frontotemporal cortex, portions of the brain that control judgment and regulate impulses. There are no effective pharmacologic treatments, but some antisocial persons receive off-label medication to dampen aggressive tendencies and curb impulsivity. Psychotropic medication is also used to treat comorbid syndromes (e.g., major depression). Cognitive-behavioral therapy may be helpful in mild cases. Family and couples therapies may be important for antisocial persons who are partnered or have offspring.
This review contains 1 figure, 2 tables, and 99 references.
Key words: aggression, antisocial personality disorder, conduct disorder, impulsivity, juvenile delinquency, lack of remorse, psychopathy, sociopathy
Neurobiology of Personality Disorders
By Kalpana Kapil-Pair, PhD; Katherine Pier, MD; Theresa Costales, MD; Jaime Wilsnack, MA; Lea Marin, MD, MPH; Marianne Goodman, MDPurchase PDF
Neurobiology of Personality DisordersPurchase PDF
Personality disorders affect an estimated 9.1% of the general population, including 25 to 50% of psychiatric outpatients and up to 80% of inpatients. They constitute heterogeneous clinical presentations characterized by interpersonal deficits owing to disturbances in self and interpersonal functioning. Personality disorders frequently co-occur with other psychiatric conditions and tend to be refractory to traditional pharmacologic treatments, and patients with these disorders have a reduced quality of life and carry significant risk of death by suicide. Research over the last 25 years has advanced our understanding of the neurobiology, neurochemistry, physiology, genetics, and epigenetics that contribute to these complex presentations. A review of the neurobiological basis of personality disorders demonstrates that, in most cases, personality pathology represents a confluence of traits that are on a spectrum with normal personality functioning and other mental disorders. Schizotypal personality disorder, borderline personality disorder, antisocial personality disorder, avoidant personality disorder, and obsessive-compulsive personality disorder are among the disorders with sufficient evidence to support their conceptualization as discrete nosologic entities. Functional neuroimaging and connectivity studies, as well as genetic and epigenetic research, have highlighted structural, neurochemical, environmental, and behavioral targets that hold promise for treatment.
This review contains 6 figures, 6 tables, and 116 references.
Key words: antisocial, avoidant, borderline, connectivity, functional magnetic resonance imaging, heritability, obsessive-compulsive, personality, personality disorder, schizotypal
Overview of Schizophrenia and Other Psychotic Disorders
By James A. Wilcox, MD, PhD; Donald W. Black, MDPurchase PDF
Overview of Schizophrenia and Other Psychotic DisordersPurchase PDF
Psychotic disorders are among the most disabling conditions and constitute a major public health problem. Described throughout recorded time, they affect as many as 5% of the population and cause a disproportionate amount of suffering and loss to society. In the chapter on schizophrenia spectrum and other psychotic disorders, the DSM-5 lists delusional disorder, brief psychotic disorder, schizophreniform disorder, schizophrenia, and schizoaffective disorder, as well as categories for substance- or medically induced psychotic disorders. The term psychosis indicates that the individual has a severe inability to interpret the surrounding environment in a realistic way. Symptoms include hallucinations, delusions, and bizarre behavior. Psychotic disorders are associated with premature death, mostly attributable to suicide. The pathophysiology and etiology of psychotic disorders are only now beginning to be understood, and treatment for these conditions remains suboptimal. Researchers are currently refining the cause of these symptoms and developing more effective treatments.
This review contains 2 tables, and 33 references.
Key words: brief psychotic disorder, delusions, hallucinations, psychosis, schizoaffective disorder, schizophrenia, schizophreniform disorder
Clinical Management of Psychotic Disorders
By Eric Epping, MD, PhD, MMEPurchase PDF
Clinical Management of Psychotic DisordersPurchase PDF
Psychotic disorders constitute a spectrum of mental illnesses that include symptoms of hallucinations, delusions, and/or disorganized thinking and behavior. Although some psychoses are short-term and reversible conditions, schizophrenia is the prototypical illness, which often develops in young adulthood and is typically chronic in its course. A complete medical and psychiatric evaluation is necessary to evaluate patients presenting with psychotic symptoms and to differentiate primary from secondary causes. Treatment of psychosis includes treatment of identifiable causal conditions, acute management of potentially harmful behaviors, prescribing antipsychotic medication, and psychotherapeutic and psychosocial interventions. A variety of antipsychotic medications are available for treatment, which must be individualized to maximize symptom reduction and to minimize short-term and long-term side effects. Long-acting injectable medications are available to improve medication adherence. In some cases, medications to counteract side effects may need to be prescribed. In more severe cases, electroconvulsive therapy may be indicated. Psychotherapy such as cognitive-behavioral therapy can reduce the severity of hallucinations and delusions. Integrated care that also includes family psychoeducation, skills training, and/or assertive community treatment is an essential part of a comprehensive multidisciplinary treatment program for the management of patients with psychotic disorders.
Key words: antipsychotic, dopamine, psychosis, psychosocial treatment, schizophrenia serotonin
Genetics of Psychosis
By Ming Tsuang, MD, PhD, DSc; Matcheri Keshavan, MD; William Stone, PhDPurchase PDF
Genetics of PsychosisPurchase PDF
Psychotic disorders such as schizophrenia are among the most disabling human illnesses. The causes of these illnesses have remained unknown, leading to much misunderstanding, stigmatization, and suffering. These illnesses are highly heritable, as evidenced by family association studies. Twin and adoption studies have pointed to the possibility of considerable environmental contributions to their causation. The identification of the chromosome locations and the specific genes is aided by linkage and association studies. Recent large-scale genome-wide association studies have pointed to a large number of genes that may together confer risk to this group of illnesses. These genes include those that have been previously implicated in the pathogenesis of psychotic disorders, such as glutamatergic neurotransmission, brain development and synapse plasticity, ion channels, and immune function. These genes may offer new ways to treat these serious illnesses, which are currently only treated with medications that target one system, namely dopamine.
This review contains 6 figures, 4 tables, and 58 references.
Key words: brain development, complement, dopamine, familial, genome, glutamate, immune function, psychosis, schizophrenia
Neurobiology of Psychotic Disorders
By Skylar Kelsven, BS; Amedeo Minichino, MD; Heline Mirzakhanian, PhD; Kristin Cadenhead, MD; Jamie Joseph, PhDPurchase PDF
Neurobiology of Psychotic DisordersPurchase PDF
Efforts to prevent or lessen the functional impact of psychosis can be informed by a better understanding of the neurobiological underpinnings at the earliest stages of the disorder. Understanding these processes early in the psychosis spectrum will in turn allow more targeted efforts to prevent or minimize functional limitations among patients with psychosis. Advances in technology have enabled the study of a host of biomarkers implicated in the neurobiology of psychosis offering unique avenues to investigate mechanisms of disease while at the same time shedding some light on more patient-tailored treatments and setting the foundation for personalized medicine in psychosis. Insights into the neurobiology of psychosis are reviewed, including findings from neuroimaging, neurocognitive, and electrophysiologic studies and findings related to the role of hypothalamic-pituitary axis activity and neuroinflammation in the emergence of psychosis. Biomarker-informed treatments are discussed, and potential promising biomarkers and related treatments are proposed.
This review contains 6 figures, 5 tables, and 89 references.
Key words: attenuated risk syndrome, biomarkers, prodrome, psychosis, schizophrenia, treatment
- Sleep and Sexual Disorders
By Atef Bakhoum, MD, PhD; Waguih William IsHak, MD, FAPAPurchase PDF
Sexual DysfunctionsPurchase PDF
Sexuality and sexual medicine is an important and often understudied aspect of medicine and psychiatry. Often, patients and physicians avoid conversations having to do with sex. The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) defines sexual dysfunctions as “a heterogeneous group of disorders that are typically characterized by a clinically significant disturbance in a person’s ability to respond sexually or to experience sexual pleasure”. This review addresses the diagnostic criteria, epidemiology, etiology, phenomenology, diagnostic work-up, treatment modalities, guidelines, and prognosis for sexual dysfunctions including male hypoactive sexual desire disorder, erectile disorder, premature and delayed ejaculation, female sexual interest/arousal disorder, female orgasmic disorder, and genito-pelvic pain/penetration disorder. The table lists sexual dysfunctions listed in DSM-5 with associated prevalence.
This review contains 1 figure, 1 table and 20 references
Key Words: DSM-5, erectile disorder, female orgasmic disorder, female sexual interest/arousal disorder, painful intercourse, premature ejaculation, sexual dysfunction
By Atef Bakhoum, MD, PhD; Waguih William IsHak, MD, FAPAPurchase PDF
Gender DysphoriaPurchase PDF
In the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), gender dysphoria (GD), previously known as gender identity disorder, is defined as distress or impairment in psychosocial, occupational, educational, or other areas of life due to a perceived disagreement between a person’s assigned gender, natal gender, and the gender currently experienced or expressed for at least 6 months. The DSM-5 mentions that one’s experienced gender may be outside of binary gender stereotypes. Diagnostic criteria are different for GD in children and in adolescents/adults. This review covers the definition, epidemiology, etiology/genetics, clinical manifestations, and studies/tests/treatments related to GD. Tables list the diagnostic criteria for GD and definitions of common terms.
This review contains 2 tables and 30 references
Key words: DSM-5, gender dysphoria, sexual reassignment surgery
By Sudhansu Chokroverty, MD, FRCP, FACPPurchase PDF
Sleep DisordersPurchase PDF
Recent research has generated an enormous fund of knowledge about the neurobiology of sleep and wakefulness. Sleeping and waking brain circuits can now be studied by sophisticated neuroimaging techniques that map different areas of the brain during different sleep states and stages. Although the exact biologic functions of sleep are not known, sleep is essential, and sleep deprivation leads to impaired attention and decreased performance. Sleep is also believed to have restorative, conservative, adaptive, thermoregulatory, and consolidative functions. This review discusses the physiology of sleep, including its two independent states, rapid eye movement (REM) and non–rapid eye movement (NREM) sleep, as well as functional neuroanatomy, physiologic changes during sleep, and circadian rhythms. The classification and diagnosis of sleep disorders are discussed generally. The diagnosis and treatment of the following disorders are described: obstructive sleep apnea syndrome, narcolepsy-cataplexy sydrome, idiopathic hypersomnia, restless legs syndrome (RLS) and periodic limb movements in sleep, circadian rhythm sleep disorders, insomnias, nocturnal frontal lobe epilepsy, and parasomnias. Sleep-related movement disorders and the relationship between sleep and psychiatric disorders are also discussed. Tables describe behavioral and physiologic characteristics of states of awareness, the international classification of sleep disorders, common sleep complaints, comorbid insomnia disorders, causes of excessive daytime somnolence, laboratory tests to assess sleep disorders, essential diagnostic criteria for RLS and Willis-Ekbom disease, and drug therapy for insomnia. Figures include polysomnographic recording showing wakefulness in an adult; stage 1, 2, and 3 NREM sleep in an adult; REM sleep in an adult; a patient with sleep apnea syndrome; a patient with Cheyne-Stokes breathing; a patient with RLS; and a patient with dream-enacting behavior; schematic sagittal section of the brainstem of the cat; schematic diagram of the McCarley-Hobson model of REM sleep mechanism; the Lu-Saper “flip-flop” model; the Luppi model to explain REM sleep mechanism; and a wrist actigraph from a man with bipolar disorder.
This review contains 14 highly rendered figures, 8 tables, 115 references, and 5 MCQs.
Clinical Management of Insomnia
By Timothy Roehrs , PhD; Thomas Roth, PhDPurchase PDF
Clinical Management of InsomniaPurchase PDF
Insomnia is the most common sleep disorder, with a prevalence of around 20%. The clearest risk factors are female gender and the presence of a psychiatric or medical disorder. The most important conceptual change in our understanding of insomnia, defined in the National Institutes of Health 2005 consensus conference, is that insomnia is a disorder itself rather than a symptom of another disorder. Specifically, insomnia is a disorder of hyperarousal. Insomniacs do not have an abnormal sleep homeostat or circadian system but rather an overactivated wake system. Cognitively, patients often complain they cannot “shut [their] brain down.” Physiologic correlates include elevated brain metabolism, increased fast electroencephalographic activity, and increased autonomic, metabolic, and hypothalamic-pituitary-adrenal axis activity. Treatment for insomnia can be divided into two categories, behavioral and pharmacologic. Another important categorization relates to self-treatment (sleep hygiene and over-the-counter drugs) versus clinician-directed therapy (cognitive-behavioral therapy for insomnia [CBT-I] and prescribed hypnotics). Among behavioral treatments are sleep restriction, stimulus control, relaxation training, and cognitive therapy. The most widely used behavioral therapy is a combination of the four treatment components referred to collectively as CBT-I. The majority of Food and Drug Administration (FDA)-approved hypnotics are drugs that occupy the benzodiazepine receptor site, which is part of the GABAA receptor complex. The hypnotic efficacy of the FDA-approved benzodiazepine receptor agonists (BzRAs) has been well documented using objective polysomnography and subjective measures of sleep induction and duration. Many BzRA side effects are associated with the desired sedative effects of the drug and relate to the pharmacokinetics, receptor subtype affinities, and dose of the drug.
Key words: behavioral therapy, GABA, histamine, insomnia disorder, melatonin, orexin, pathophysiology, pharmacotherapy
By Lancer Naghdechi, MS, DO; Atef Bakhoum, MD, PhD; Waguih William IsHak, MD, FAPAPurchase PDF
Paraphilic DisordersPurchase PDF
Sexuality and sexual medicine are important and often understudied aspects of medicine and psychiatry. Often, patients and physicians avoid conversations regarding sex. A paraphilic disorder is diagnosed when a paraphilia, defined by the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) as “any intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, physically mature, consenting human partners”, results in distress or impairment to the individual, personal harm, or risk of harm, to others. This review covers the definition, diagnostic criteria, epidemiology, etiology, phenomenology, diagnostic work-up, treatment modalities, guidelines, and prognosis of paraphilias including voyeurism, exhibitionism, frotteurism, sexual masochism disorder, sexual sadism disorder, pedophilic disorder, and transvestic disorder. The table and figure list paraphilic disorders listed in the DSM-5 and paraphilias in the Other specified paraphilic disorders section of the DSM-5.
This review contains 1 figure, 1 table, and 15 references.
Key Words: DSM-5, exhibitionism, fetish, frotteurism, paraphilia, paraphilic disorder, pedophilic disorder, sexual masochism disorder, sexual sadism disorder, transvestic disorder, voyeurism
By KyoungBin Im, MD, MSPurchase PDF
Parasomnias have long been recognized as part of sleep-related disorders or diseases in the mental disorders classification system such as Diagnostic and Statistical Manual of Mental Disorders. Nevertheless, many parasomnia symptoms are considered as a transient deviation from the norm in otherwise normal subjects due to disrupted status of consciousness. Sleep states are classified as rapid eye movement (REM) sleep and non-REM (NREM) sleep; similarly, parasomnias are classified as NREM-related parasomnias and REM-related parasomnias. NREM-related parasomnias share common pathophysiology of arousal-related phenomenon out of slow-wave sleep. Although listed as REM parasomnia disorders, nightmares and sleep paralysis are still considered comorbid symptoms or signs of other sleep disorders or mental disorders. Only REM sleep behavior disorder (RBD) is considered a relatively homogenous disease entity among all parasomnia diagnoses. Although RBD is the most newly added disorder entity in parasomnias, it is the most rigorously studied parasomnia such as RBD is strongly and clearly associated with concomitant or future developing neurodegenerative disease.
This review contains 1 figure, 4 tables, and 18 references.
Key Words: confusional arousals, dream enactment, pseudo-RBD, REM sleep behavior disorder, sleep-related eating, sleep terror, sleepwalking
Gay, Lesbian, and Transgender Issues in Psychiatry
By Jonathan R. Hester, MD, PGY-2; Julie M. Praus, MDPurchase PDF
Gay, Lesbian, and Transgender Issues in PsychiatryPurchase PDF
This review is intended to give an overview of psychiatric considerations for the lesbian, gay, bisexual, and transgender (LGBT) population. The history of LGBT-related diagnoses in the DSM is discussed along with the epidemiology of various mental disorders in the LGBT population, with several diagnoses having a higher incidence including depression, anxiety, substance use disorders, self-harm, and suicidal ideation or attempt. To explain these discrepancies, several theories and models are explored, specifically the minority stress model and adverse childhood events. Additionally, recommendations for clinical psychiatric practice are explored including affirmative therapy and transgender-affirming cognitive behavioral therapy, two interventions specifically studied in the LGBT population as well as overall goals of treatment when treating patients struggling with their gender identity.
This review contains 5 tables, and 35 references.
Key Words: adverse childhood events, affirmative therapy, bisexual, gay, lesbian, LGBT, minority stress, transgender, transgender-affirming cognitive behavioral therapy
- Somatic Symptom Disorders
By James Amos, MD; Michael Strong, MD, PGY-2 ; Donald W. Black, MDPurchase PDF
Factitious DisordersPurchase PDF
Factitious disorder (FD) is a psychiatric disorder in which patients deliberately perpetrate or lie about medical and/or psychiatric illness in themselves or others. Although it has been thought to be driven by the need to take the patient role, no body of research has clearly identified the underlying motivation, cause, or treatment for it. Illness deception, along with the similarity to other diagnostic categories, such as somatic symptom disorder, personality disorder, and malingering (which is not considered a mental illness but can be a focus of clinical attention), has hindered basic and clinical research into the nature and treatment of FD. Still, moving psychiatric treatment of FD forward can take advantage of tools already available to clinicians, including motivational interviewing techniques to facilitate empathic confrontation in the general hospital. Despite the lack of treatment studies, employing therapies known to be effective for borderline personality disorder, which is similar in many ways to FD, for FD patients willing to participate might be helpful.
This review contains 4 figures, 5 tables and 26 references
Key words: factitious disorder imposed on another, factitious disorder imposed on self, malingering, medically unexplained symptoms, Munchausen by proxy, Munchausen syndrome, pseudologia fantastica, somatic symptom disorders
By Christopher Sharp, MD; Scott Simpson, MD, MPHPurchase PDF
Malingering DisordersPurchase PDF
Malingering is the “intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives.” Malingering is difficult to identify and a challenge for physicians to manage. There are innumerable incentives for malingering, including financial gain, housing, and controlled substances. Although there is no definitive way to identify malingering, clues that suggest malingering include inconsistencies in the history and examination, discrepancies among collateral informants, and the results of neuropsychological testing. By recognizing how malingering may be a rational, adaptive choice for patients to address their needs, psychiatrists can preserve the doctor-patient relationship and build an alliance to achieve the patient’s goals in a more productive manner. Pitfalls for clinicians treating malingering patients include burnout, aversive countertransference reactions, and inadequate treatment of comorbid medical or psychiatric conditions. Psychiatrists must also be attentive to appropriate documentation and personal safety. The long-term prognosis of malingering patients is not well understood.
This review contains 5 figures, 7 tables, and 81 references.
Key words: antisocial personality disorder, confrontation, countertransference, external incentive, factitious disorder, forensic psychiatry, malingering
Somatic Symptom Disorder and Related Conditions
By Stephen Thielke, MD, MSPurchase PDF
Somatic Symptom Disorder and Related ConditionsPurchase PDF
Somatic symptom disorder (SSD) is a novel construct, first presented in the DSM-5. It has two criteria: distressing or impairing bodily symptoms and excessive or disproportionate thoughts, feelings, or behaviors directed toward those symptoms. The criteria must be applied critically to make sense logically and clinically. The framework does not suggest any causal relationship between the elements. SSD uses a different formulation than in previous constructs, with no requirement that symptoms be medically unexplained. Little research has been conducted about SSD, and it is inappropriate to draw conclusions from similar diagnoses. Therefore, almost nothing is known about epidemiology, natural history, and treatment response in SSD. Health anxiety disorder is similar to SSD, but without significant somatic symptoms. Conversion disorder and factitious disorder entail more specific findings than does SSD. Providers should carefully apply diagnostic criteria for SSD, focus on the individual’s distress, and consider how this diagnosis influences the provider-patient relationship. Future research will refine the understanding of the condition and therapeutic approaches to it.
This review contains 1 figure, 5 tables, and 39 references.
Key words: behaviors, conversion disorder, disproportionate, excessive, factitious disorder, feelings, health anxiety, somatic symptom disorder, somatization, thoughts
Conversion Disorder and Its Clinical Management
By Sonali Kothari, MD; Laura Marie LaPlante, MD; Anna Borisovskaya, MD; William Carspecken, MD, MSc, MBA; Marcella Pascualy, MDPurchase PDF
Conversion Disorder and Its Clinical ManagementPurchase PDF
This review discusses the complex path to the current definition of conversion disorder (CD), from ancient Egypt to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), and the way that our understanding of the disorder’s etiology and pathophysiology shaped both its name and its diagnostic criteria. We describe emergence of a comprehensive theory of CD’s pathophysiology, in which an overly sensitive limbic system, shaped by traumatic experiences, changes neural networks responsible for perceptual experiences and movement plans, ultimately producing CD symptoms. We also discuss the importance of early diagnosis of CD as a delayed diagnosis is associated with worse outcomes and precludes appropriate treatment. A variety of diagnostic techniques exist to help distinguish between functional neurologic symptoms and organic disease. Among treatments, we highly recommend therapeutic disclosure of the diagnosis and cognitive-behavioral therapy, which has a small but high-quality evidence base to support its use in the treatment of CD. Collaboration between psychiatrists and neurologists may ensure appropriate diagnosis and treatment of this challenging condition. Prognosis of CD is generally poor, with comorbid personality disorder and delayed diagnosis correlating with worse outcomes.
This review contains 4 figures, 6 tables, and 87 references.
Key words: conversion disorder, functional neurologic disorder, hysteria, medically unexplained symptoms, psychogenic movement disorder, psychogenic nonepileptic seizures
By Shadi Doroudgar, PharMD, BCPS, CGP, BCPP; Paul Perry, BPharm, PhDPurchase PDF
General PsychopharmacologyPurchase PDF
Initial development of neuropsychiatric medications relied heavily on serendipitous discovery rather than targeted drug designs. Nowadays, drug discovery targets include receptors, enzymes, and transporters. The human brain comprises many neurons, each being connected to other neurons via synapses. Neurotransmission occurs when a presynaptic neuron projects its terminal segment to form a connection or synapse with an adjacent postsynaptic neuron. When stimulated, neurotransmitters that are stored in small vesicles in the presynaptic neuron are released into an interneuronal gap called the synaptic cleft. Serotonin, dopamine, norepinephrine, γ-amino butyric acid, glutamate, and acetylcholine are among the primary neurotransmitters and chemicals that play important roles in neuropsychiatric functions. As such, they are often common targets of drug development. Grasping the basics of neurotransmission, enzyme degradation, and receptor and transporter pharmacology is essential in understanding today’s FDA-approved pharmaceuticals. This neuropharmacology primer will allow the rational and appropriate clinical selection of pharmacotherapy and accurate anticipation of clinical effects following use.
This review contains 1 figure and 45 references
Key Words: acetylcholine, dopamine, γ-amino butyric acid, glutamate, neurotransmission, norepinephrine, pharmacology, psychiatric medications, psychopharmacology, receptor, serotonin
By Shadi Doroudgar, PharMD, BCPS, CGP, BCPP; Baovy Dang, MSPurchase PDF
Antidepressant medications have numerous clinical uses in the field of psychiatry. There are many antidepressant classes, with the selective serotonin reuptake inhibitors and serotonin norepinephrine reuptake inhibitors being commonly used in clinical practice for depression and anxiety. Although these medications are effective, complete clinical effect is not rapid and full relief of symptoms can take more than a month. However, side effects with antidepressants can be expected to occur upon initiation of treatment and may lead to patient nonadherence. Education and appropriate patient counseling are necessary to assure that the therapeutic effects of medications are maximized. Treatment with antidepressants should be tailored to patient-specific criteria.
This review contains 1 figure, 4 tables and 43 references
Key Words: antidepressants, FDA-approved, obsessive-compulsive disorder, monoamine oxidase, MAOIs, selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors, tricyclic antidepressants.
By Shadi Doroudgar, PharMD, BCPS, CGP, BCPP; Elham Eftekhari, Pharm D CandidatePurchase PDF
Antipsychotics are used to treat a variety of disorders. They are commonly used in the management of psychiatric symptoms of schizophrenia and bipolar disorder. However, among other uses, they also have shown efficacy in treating symptoms of autism, nausea/vomiting, and hiccups. In the case of psychiatric uses, long-term maintenance treatment is typically needed to avoid relapse of symptoms. Antipsychotic choice based on the efficacy is difficult; therefore, in many cases side-effect profile of an agent becomes relevant when deciding on a treatment regimen. Side effects of antipsychotics include extrapyramidal symptoms, metabolic adverse effects, hematologic changes, anticholinergic effects, and QTc prolongation. As clinicians, it is important to be aware of these side effects and their monitoring parameters. These can be managed by discontinuing a drug, decreasing dosage, changing the drug to a different antipsychotic, and using another drug for their treatment.
This review contains 5 tables and 97 references
Key Words: antipsychotics, atypical antipsychotics, clozapine, D2 receptor, extrapyramidal symptoms, FDA-approved, REMS, typical antipsychotics
By Shadi Doroudgar, PharMD, BCPS, CGP, BCPP; Gurjit Bains, PharmD CandidatePurchase PDF
The underlying pathophysiology of anxiety disorders revolve around neurotransmitter transmission, the pharmacologic target of common medication treatments. Pharmacologic treatment of anxiety disorders generally consists of benzodiazepines for short-term relief of anxiety symptoms and antidepressants as a long-term therapy. Benzodiazepines use should be limited because of habit-forming properties, dependence, and risk of adverse effects. Antidepressants are the typically preferred initial agents for long-term use due to efficacy and lack of dependence. Anxiety disorders may occur as comorbidities with other psychiatric disorders. Other pharmacologic agents are utilized as alternative therapy for patients who do not respond to mainstay therapy or are not candidates for the treatment with antidepressants.
This review contains 1 figure, 6 table and 77 references
Key Points: anxiety disorders, benzodiazepines, generalized anxiety disorder, norepinephrine, panic disorder, social anxiety disorder, selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors
Mood Stabilizers: Implementing Combined Treatment Regimens in Bipolar Disorder
By Charles Bowden, MD; Melissa Martinez, MDPurchase PDF
Mood Stabilizers: Implementing Combined Treatment Regimens in Bipolar DisorderPurchase PDF
Patients with bipolar disorders spend a greater proportion of their illness in a depressed or mixed state rather than experiencing either mania or hypomania. Over the past 20 years, most major pharmaceutical companies have either reduced or abandoned the research and development of novel psychiatric drugs, exiting the development of new, safe, efficacious, and tolerable treatment regimens for bipolar disorder. Therefore, optimizing the current treatments available is critical. We review studies of the last 15 years that provide guidance relevant to managing the maintenance phase of bipolar disorders. Based on these data, we provide recommendations for effective treatment planning and implementation, principally for the maintenance phase care of persons with bipolar disorder. We also discuss strategies for implementing medication regimens, differentiating strategies for maintenance phase treatment from those of acute phase treatment. Assessing key symptoms that are sensitive to change is critical for longitudinal assessments and treatment planning for patients with bipolar disorders. In most studies, only a subset of rating scale items differentiate patients with good responses from those without. Identified symptoms include racing thoughts, less need for sleep, hyperactivity, increased activity, and increased energy. We developed a procedure for using Multistate Outcome Analysis of Treatment (MOAT) in bipolar disorders. MOAT integrates efficacy and tolerability data during studies to provide information about the quantity and quality of time spent in distinct mood states. The protocol developed will be useful for assessing treatment strategies in bipolar disorder.
This review contains 4 figures, 7 tables and 32 references
Key words: bipolar, depression, lithium, mania, mixed, mood stabilizer, survival analysis, symptom domains, valproate
Neuroleptic Malignant Syndrome and Serotonin Syndrome
By Richard Sanders, MD; Richard Krysiak, MDPurchase PDF
Neuroleptic Malignant Syndrome and Serotonin SyndromePurchase PDF
Serotonin syndrome (SS) and neuroleptic malignant syndrome (NMS) are iatrogenic life-threatening conditions with similar clinical symptoms. Altered mental status, rigidity, and autonomic instability are common in both serotonin overload and toxic dopamine antagonism. It is paramount that providers understand the key differences between these two pathologies, as pharmacologic treatments can exacerbate the condition if SS is mistaken for NMS or vice versa. Hyperreflexia, clonus, diarrhea, and vomiting suggest the excessive activity of serotonin circuits in SS, whereas prominent rigidity and hyporeflexia suggest the underactivity of dopamine circuits in NMS. Supportive care and discontinuing the offending agent(s) are keys to treating both syndromes, but serotonin antagonists (eg, cyproheptadine) could be helpful in SS, whereas NMS may sometimes benefit from muscle relaxants (eg, dantrolene) and dopamine agonists (eg, bromocriptine). Following recovery, decisions about further use of an inciting agent (or similar agents) require reconsideration of risks, benefits, and alternatives, based on newly realized hazards. It is usually important to wait at least 2 weeks before rechallenge with any drugs resembling the inciting agents.
This review contains 1 figure, 5 tables, and 29 references.
Key Words: bromocriptine, cyproheptadine, dantrolene, Hunter criteria, neuroleptic malignant syndrome, parkinsonism, serotonin syndrome
Consult-liaison (psychosomatic) Psychiatry
By Tracy D. Gunter, MDPurchase PDF
Consult-liaison (psychosomatic) PsychiatryPurchase PDF
Overview of Forensic Psychiatry
By Tracy D. Gunter, MDPurchase PDF
Overview of Forensic PsychiatryPurchase PDF
Overview of Ethics in Psychiatry
By Cheryl Erwin, JD, PhD; Janeta Tansey, MD, PhDPurchase PDF
Overview of Ethics in PsychiatryPurchase PDF
This review of psychiatry ethics is intended for residents, fellows, and practicing psychiatrists. We provide an overview of the historical sources of ethical reasoning and give practitioners a structured method for analysis of ethical dilemmas typically encountered in the practice of medicine. Through the use of case examples, we explain how difficult situations often challenge received knowledge and superficial opinion about the ethical options present and justifiable in real-life situations. This review will appeal to the higher callings and traditions of medicine and encourage the physician who is faced with ethical decisions about which reasonable practitioners may disagree. Tools of ethical reasoning provide a means for making ethical decisions that are grounded in history and tradition.
This review contains 1 figure, 6 tables, and 30 references.
Key words: confidentiality, decision making, doctor-patient relationship, ethics, informed consent, narrative, principles, professionalism, respect, virtue
Cultural Diversity in Psychiatry
By Ryan Harris, MD; Joanna Chambers, MD; Mary Guerriero Austrom, PhD; Danielle Patterson, MDPurchase PDF
Cultural Diversity in PsychiatryPurchase PDF
This purpose of this review is to provide general guidelines to practicing psychiatrists and psychologists on cultural diversity in the discipline. Diversity and mental health is a complex topic in a complex discipline, and our goal is to contribute to an understanding of how cultural identity affects our work. This review does not explicitly state how to treat any one cultural group. Rather, it is a tool for psychiatrists and other mental health providers to begin a sensitive and helpful conversation with patients of all backgrounds and a way to explore their own cultural identities. As our nation becomes increasingly diverse, providers are expected to understand how a patient’s cultural identity impacts the presenting problem and, ultimately, treatment. In addition, an ever-present opportunity remains for mental health professionals to explore their own cultural identity and how it may be involved in conscious and unconscious biases, which, in turn, also impact how they interpret, treat, and manage care. We explore key aspects of diversity with the goal of cultivating a deeper level of insight and awareness among psychiatrists in training and those currently in practice when caring for patients with diverse backgrounds. The guidelines offer a starting point toward delivering culturally competent care and, coupled with a commitment to lifelong learning from psychiatrists and other mental health professionals, can help minimize the stigma of traditionally marginalized groups.
This review contains 7 tables, and 67 references.
Key words: aging, diversity, LGBTQ, psychiatry, race, religion
Overview of Legal Issues in Psychiatry
By Tracy D. Gunter, MDPurchase PDF
Overview of Legal Issues in PsychiatryPurchase PDF
Psychiatrists routinely encounter legal and regulatory issues in the practice of psychiatry. This review provides an overview of the psychiatrist’s duties and responsibilities in the doctor-patient relationship and common legal issues arising in clinical practice, with reference to US statutory and regulatory practices. The field of forensic psychiatry is described, and the roles of the forensic evaluator and the treatment provider are compared.
This review contains 2 figures, 5 tables, and 64 references.
Key words: civil commitment, confidentiality, duty to third parties, forensic psychiatry, guardianship, gun ownership, medical decision making, medical marijuana, risk assessment
Mistreatment of Elders
By Emily I Gorman, MD; Judith Linden, MDPurchase PDF
Mistreatment of EldersPurchase PDF
Elder mistreatment affects a considerable proportion of individuals older than 60 to 65 years of age and may include intentional abuse (physical, sexual, emotional, or financial) and neglect. As the proportion of the population that is older than 65 years of age increases, elder mistreatment will become an increasingly common issue. Only a minority of cases of elder abuse are reported; thus, an interview with the patient should be conducted in private if elder mistreatment is suspected. Patient risk factors for elder mistreatment include cognitive or behavioral impairment, poor physical health, and poor social supports. This review examines the approach to the patient, as well as definitive treatment, disposition, and outcomes for victims of elder abuse. The figure shows an algorithm for elder abuse assessment and intervention. Tables list types of elder abuse, factors predisposing to elder mistreatment, indicators of abuse, and the Elder Abuse Suspicion Index.
This review contains 1 highly rendered figure, 4 tables, and 42 references.
Headache and Facial Pain
By Elizabeth W. Loder, MD, MPHPurchase PDF
Headache and Facial PainPurchase PDF
Headaches are a near-universal experience, with a 1-year prevalence of 90% and a lifetime prevalence of 99%. Headaches and pain to the head account for roughly 3% of visits to US emergency departments annually, making them the fourth most common reason for seeking emergency care. There are numerous types of headaches, and although the majority are benign, types exist that may result from serious and potentially life-threatening causes. As such, it is important for the physician to consider a broad differential diagnosis for every headache patient. This review discusses the classification of headaches, identifies pain-sensitive structures in the head, discusses the history and examination in patients with headache, and describes many of the primary and secondary headaches. Figures show the areas of the brain sensitive to pain; 1-year prevalence of migraine in men, women, and children; frequency of attacks in migraineurs; prevalence of headaches by age group and in patients with cerebrovascular disorders; and symptoms of idiopathic intracranial hypertension. Tables list the major categories of headache disorders, key elements of the headache history, helpful questions to ask, features of selected primary and secondary headaches, reasons to consider neuroimaging, efficacy of selected over-the-counter medications, triptans available in the United States, medication options for urgent or emergency treatment of migraine, selected preventive medications for migraine, generally accepted indications for preventive treatment, general principles for the use of preventive medications, titration schedules for preventive medication, interval or short-term preventive treatment of menstrual migraine, strategies for managing increase in migraines in patients starting estrogen replacement therapy, transition medications for rapid, temporary suppression of headaches, medications possibly effective for cluster and hypnic headaches, differential diagnosis of the acute, severe, new-onset headache, and etiologies of papilledema and headache.
This review contains 6 highly rendered figures, 20 tables, and 112 references.
Neuroimaging for the Clinician
By Joshua P Klein, MD, PhDPurchase PDF
Neuroimaging for the ClinicianPurchase PDF
Modern neuroimaging has revolutionized the practice of neurology by allowing visualization and monitoring of evolving pathophysiologic processes. High-resolution magnetic resonance imaging (MRI) can now resolve structural abnormalities on a near-cellular level. Advances in functional imaging can assess the in vivo metabolic, vascular, and functional states of neuronal and glial populations in real time. Given the high density of data obtained from neuroimaging studies, it is essential for the clinician to take an active role in understanding the nature and significance of imaging abnormalities. This chapter reviews computed tomography and MRI techniques (including angiography and advanced sequences), specialized protocols for investigating specific diagnoses, risks associated with imaging, disease-specific imaging findings with general strategies for interpretation, and incidental findings and artifacts. Figures include computed tomography, T1- and T2-weighted signal intensity, diffusion-weighted magnetic resonance imaging, magnetic resonance spectroscopy, imaging in epilepsy and dementia, extra-axial versus intra-axial lesions, typical lesions of multiple sclerosis, spinal imaging, spinal pathology, vascular pathology, intracranial hemorrhage, and common imaging artifacts. Tables list Hounsfield units, patterns of enhancement from imaging, advanced techniques in imaging, magnetic resonance imaging sequences, and the evolution of cerebral infarction and intraparenchymal hemorrhage on magnetic resonance imaging.
This chapter contains 213 references.
Pain Syndromes Other Than Headache
By Edgar L. Ross, MDPurchase PDF
Pain Syndromes Other Than HeadachePurchase PDF
Pain is experienced within a complex biologic, emotional, psychological, and social context that may defy physical examination, diagnostic procedures, and laboratory tests. This chapter aims to empower internists to improve their medical practices in pain management. It provides a scientific background that covers nociception and how sensory processing occurs at multiple levels in the body. Clinical assessment is detailed, as well as diagnostic categories that include mixed or uncertain chronic pain syndromes (back pain, fibromyalgia, postamputation pain, pain from cancer and bone) and neuropathic pain syndromes (polyneuropathy, mononeuropathy multiplex, ganglionopathy, genetic disorders, focal and regional syndromes). Treatment of chronic pain can be surgical or interventional. Pharmacologic treatment for acute and chronic nociceptive pain includes special considerations for geriatric and terminal patients. For treatment of neuropathic pain, medications are the major component. One tables lists iatrogenic nerve injuries that can cause posttraumatic neuralgia and complex regional pain syndrome. Other tables detail stepwise pharmacologic management of neuropathic pain and cite recommendations on opioid use from the Centers for Disease Control and Prevention. One figure illustrates how pain transducers monitor and influence tissue conditions. Other figures show sensory processing in the spinal cord dorsal horn, physical findings in the feet of patients with bilateral foot pain from small-fiber polyneuropathy, illustrate how examination can identify specific nerve injuries causing chronic pain, and provide classification of chronic pain syndromes. This chapter contains 82 references.
By Sarah Wagner, DO; Robert Gerstman, DOPurchase PDF
Delirium is a disturbance of attention and awareness, which develops over a short period of time. It is a change in a person’s baseline and fluctuates throughout the course of the day.1 Delirium can accompany almost any serious medical illness. It is an independent risk factor for increasing a person’s morbidity and mortality. Delirium is associated with an increased length of hospital stay and an increase in health care cost.2 There is growing literature to assist in the diagnosing and treatment of patients with delirium. This article dives into the recent research addressing the pharmacologic and nonpharmacologic methods to treat delirium. Various pharmacologic interventions have been studied over the past several years including the use of melatonin, ramelteon, dexmedetomidine, and antipsychotics.
This review contains 2 tables and 17 references.
Key Words: acute brain failure, altered mental status, Confusion Assessment Method, critical care, delirium, encephalopathy, ICU, RASS, Richmond Agitation-Sedation Scale
Women’s Health: Treating Survivors of Sexual AssaultPurchase PDF
Women’s Health: Treating Survivors of Sexual AssaultPurchase PDF
Psychiatry and Interpersonal Communication
By Brent D Schnipke, MD; Randon S Welton, MDPurchase PDF
Psychiatry and Interpersonal CommunicationPurchase PDF
Interpersonal and communication skills (ICS) are central to the practice of psychiatry. These skills are broad and can be defined in several ways, and several frameworks are presented, using the Accreditation Council for Graduate Medical Education competencies as well as other published guidelines. ICS are essential to good patient care and require special knowledge in psychiatry due to the particular diseases that are encountered. ICS are equally valuable to psychiatrists in communicating with family members, other physicians, and other members of the healthcare team, as well as in education and leadership. Recommendations for adapting ICS to these circumstances are outlined. For psychiatry trainees, regular evaluation of ICS is mandated but is also recommended for practicing psychiatrists. If deficiencies are noted, strategies for addressing them can be pursued, and suggested improvement practices are provided.
This review contains 2 figures, 4 tables, and 21 references.
Key Words: communication, communication skills, consultation-liaison psychiatry, doctor-patient communication, interpersonal, psychiatry, psychotherapy, therapeutic alliance, rapport
Fibromyalgia as a Biopsychosocial Model for the Intersections of Physical and Emotional PainPurchase PDF
Fibromyalgia as a Biopsychosocial Model for the Intersections of Physical and Emotional PainPurchase PDF
Resource Management: Parity and Access to CarePurchase PDF
Resource Management: Parity and Access to CarePurchase PDF
- Physician Competencies and Mechanisms
Complementary, Alternative, and Integrative Medicine
By Helene M. Langevin, MDPurchase PDF
Complementary, Alternative, and Integrative MedicinePurchase PDF
Complementary and alternative medicine (CAM) refers to a group of diverse medical and health care systems, practices, and products that are not considered to be part of conventional or allopathic medicine. Common CAM practices (e.g., acupuncture, meditation, and therapeutic massage) are gradually becoming incorporated into conventional care in response to patients looking to alternative sources for information and advice about health matters and increased understanding of various CAM methods through evidence-based testing. However, although the claims of some methods are supported with academic research, well-founded concerns remain in many popularized CAM practices regarding the lack of evidence and placebo effects. It is thus imperative for physicians to be comfortable in discussing CAM-related topics with patients and be able to appropriately and informatively guide them in a way that harnesses potential benefits and avoids potential harm. In this review, the major CAM therapies in the United States are examined, including the settings in which they are being used, evidence base status, and efficacy of some of the most commonly used modalities.
This review contains 5 figures, 21 tables, and 123 references.
Keywords: Alternative medicine, complementary medicine, acupuncture, homeopathy, osteopathy, chiropractic, massage therapy, naturopathy
By Bradley J. Robottom, MD; Jason S. Hawley, MD; William J. Weiner, MDPurchase PDF
Movement DisordersPurchase PDF
The term movement disorders encompasses a wide range of conditions that cause abnormal movements. This review discusses hypokinetic movement disorders, including bradykinesia, akinesia, akinetic rigid syndrome, and Parkinsonism, an akinetic rigid syndrome that is one of the most common of all the movement disorders which is most often a manifestation of Parkinson disease (PD). The review looks at the epidemiology, etiology, pathology, diagnosis, treatment, and management of PD. Other parkinsonian syndromes include progressive supranuclear palsy, corticobasal syndrome, multiple system atrophy, vascular parkinsonism, normal pressure hydrocephalus, drug-induced parkinsonism, and dementia associated with Parkinson disease. Hyperkinetic movement disorders include tremor, dystonia, tics, myoclonus, and chorea. They include Huntington disease, Wilson disease, tardive dyskinesia, Tourette syndrome, and essential tremor. Figures in this review include examples of generalized dystonia, moderate parkinson disease, affected handwriting, Kayser-Fleischer ring, cervical dystonia, head deviation, and writer's cramp. Tables provide clinical definitions, clues to drug-induced parkinsonism, and a list of drugs that can cause parkinsonism.
This review contains 129 references.
By Kevin A. Kerber, MD, MS; Robert W. Baloh, MDPurchase PDF
Dizziness is the quintessential symptom presentation in all of clinical medicine. It is a common reason that patients present to a physician. This chapter provides background information about the vestibular system, then reviews key aspects of history-taking and examination of the patient, then discusses specific disorders and common presentation types. Throughout the chapter the focus is on neurologic and vestibular disorders. Normal vestibular anatomy and physiology are discussed, followed by recommendations for history-taking and the physical examination. Specific disorders that cause dizziness are explored, along with common causes of non-specific dizziness. Common presentations are discussed, including acute severe dizziness, recurrent attacks, and recurrent positional vertigo. Finally, the chapter looks at laboratory investigations in diagnosis and management. Figures include population prevalence of dizziness symptoms, the anatomy of inner structures, primary afferent vestibular nerve activity, the head thrust test, the Dix-Hallpike maneuver, the supine positional test, the canalith repositioning procedure, and the barbecue roll maneuver. Tables list physiologic properties and clinical features of the components of the peripheral vestibular system, information to be acquired from history of the present illness, common symptoms patients report as dizziness, examination components, distinguishing among common peripheral and central vertigo syndromes, common causes of nonspecific dizziness, types of dizziness presentations, relevant imaging abnormalities on neuroimaging studies, vestibular testing components, and medical therapy for symptomatic dizziness.
This review contains 8 highly rendered figures, 10 tables, and 68 references.
Stroke and Other Cerebrovascular Diseases
By Scott E. Kasner, MD, MSCE, FAHA, FAAN; Christina A Wilson, MD, PhDPurchase PDF
Stroke and Other Cerebrovascular DiseasesPurchase PDF
Stroke is a leading cause of neurologic morbidity and mortality, and rapid treatment is key for a good outcome. This review addresses the epidemiology, common presenting symptoms, causes, and treatment of ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage. Current recommendations for the emergent evaluation and treatment of an acute ischemic stroke are highlighted, including recently updated indications and contraindications for intravenous recombinant tissue plasminogen activator administration and recent guidelines for the expanded role of endovascular mechanical embolectomy for stroke due to acute large vessel occlusion. An algorithm of diagnostic evaluations to assist with identification of the cause of ischemic stroke is offered. Evidence-based primary and secondary stroke prevention is discussed, including the ideal choice of antithrombotic based on identified stroke mechanism and optimal risk factor management. Best practice supportive measures for the post-stroke patient are highlighted, including recent guidelines for the management of elevated intracranial pressure. Management of uncommon causes of ischemic stroke is also addressed.
Key Words: Intracerebral hemorrhage, ischemic stroke, recombinant tissue plasminogen activator, subarachnoid hemorrhage
By Shamik Bhattacharyya, MD; Jennifer L. Lyons, MDPurchase PDF
In 2013, the International Encephalitis Consortium proposed clinical criteria for acute encephalitis consisting of 24 hours of altered level of consciousness, lethargy, or personality change and at least three additional supportive features. Although viruses are the most common cause of acute encephalitis, not all encephalitides are acute, viral, or even infectious. Chronic encephalitis can be pathologically similar to acute encephalitis, but the causative agents and clinical manifestations vary. Management of encephalitis is largely supportive; however, for many common encephalitides primary preventive approaches exist. This module reviews the epidemiology, manifestations, diagnosis, management, and prevention of various encephalitides, including herpes family encephalitis (herpes simplex virus, varicella-zoster virus, cytomegalovirus, human herpesvirus 6), arbovirus encephalitis (West Nile virus, eastern equine encephalitis virus, tick-borne encephalitis virus, Japanese encephalitis virus), other encephalitides associated with viruses (influenza virus, human immunodeficiency virus, John Cunningham virus, rabies virus), encephalitides associated with bacteria (Mycoplasma pneumonia, Listeria monocytogenes), and autoimmune encephalitis (acute disseminated encephalomyelitis, paraneoplastic and other autoimmune encephalitides, immune reconstitution inflammatory syndrome). Tables include the International Encephalitis Consortium’s supportive feature of encephalitis, differential diagnosis for magnetic resonance imaging (MRI) findings in the patient with suspected encephalitis, diagnostic considerations for triaging workup of infection-associated encephalitis, differential diagnosis of arboviral infections by location of travel or residence, and preventive strategies for select infectious encephalitis. Figures include MRIs showing patients with herpes simplex encephalitis, varicella-zoster virus, eastern equine encephalitis, HIV, Listeria monocytogenes, acute disseminated encephalomyelitis, acute hemorrhagic leukoencephalitis, and immune reconstitution inflammatory syndrome.
This module contains 8 highly rendered figures, 5 tables, 78 references, and 5 MCQs.
By Hélio A G Teive, MD, PhD; Orlando G P Barsottini, MD, PhDPurchase PDF
Ataxia is a disorder of balance and coordination. The most common forms are cerebellar ataxia and afferent/sensory ataxia. Ataxias can be classified as primary or secondary, as well as hereditary, nonhereditary degenerative, and sporadic. This review covers the primary (congenital, hereditary, and nonhereditary degenerative ataxias) and secondary cerebellar ataxias and afferent/sensory ataxias. Hereditary ataxias are classified as autosomal recessive cerebellar ataxias (such as Friedreich ataxia and ataxia-telangiectasia), autosomal dominant cerebellar ataxias (currently known as spinocerebellar ataxias, such as spinocerebellar ataxia type 3 or Machado-Joseph disease), episodic ataxias, X-linked cerebellar ataxias, and mitochondrial ataxias. Idiopathic degenerative cerebellar ataxias include the cerebellar form of multiple system atrophy (MSA-C) and idiopathic late-onset cerebellar ataxias. Secondary cerebellar ataxias or acquired ataxias include ataxias due to exogenous or endogenous nongenetic causes, such as toxic, paraneoplastic, immune mediated, nutritional, infectious, and secondary to focal injury to the cerebellum. Afferent/sensory ataxia represents a special group of ataxias with many possible causes and is associated with peripheral neuropathies, dorsal root ganglionopathies, sensory nerve root involvement, and posterior spinal column involvement. Figures show several clinical and radiologic (magnetic resonance imaging) signs of autosomal recessive, autosomal dominant ataxias, and multiple system atrophy (type C). Tables list the most common neurologic signs of cerebellar and afferent/sensory ataxias, the main forms of autosomal recessive and autosomal dominant cerebellar ataxias, and the most common causes of secondary cerebellar and afferent/sensory ataxias.
Key words: afferent/sensory ataxias, ataxias, autosomal recessive cerebellar ataxias, congenital ataxias, nonhereditary degenerative ataxias, secondary cerebellar ataxias, spinocerebellar ataxias
This review contains 5 highly rendered figures, 4 tables, and 99 references.