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Psychiatric Disorders Mood Disorders Childhood Disorders Psychotic Disorders Anxiety Disorders Eating Disorders Sleep Disorders Somatoform Disorders 6 Major depressive disorder Oppositional defiant disorder Bipolar disorder Schizophrenia Panic attack Schizophreniform disorder Posttraumatic stress disorder Anorexia nervosa Obstructive sleep apnea Somatization disorder 129 Kibble_Sec06_129-139.indd 129 4/24/13 3:34 PM Kibble_Sec06_129-139.indd 130 4/24/13 3:34 PM A 46-year-old male presents to his primary care physician with a complaint of trouble sleeping. He states that he lies in bed for up to 3 hours before falling asleep but does not have problems staying asleep. Further questioning reveals that the patient lost his job 5 months ago and his family has been relying on his wife’s part-time income. He states that he has been feeling depressed 6 for the past several months, as he has not been able to find another source of employment to support his family. He feels it is hopeless to continue to find a job, and now spends most of his time now on the couch watching TV. He has no interest in activities he used to enjoy. He reports a decreased appetite but denies weight loss, problems concentrating, substance abuse, or suicidal ideations. His only past medical history includes stage I hypertension well controlled with hydrochlorothiazide. Physical examination reveals an appropriately dressed male with a restricted affect and linear thought process. 130 Kibble_Sec06_129-139.indd 130 4/24/13 3:34 PM Major Depressive Disorder This patient has major depressive disorder. Although there are often several criteria for many diagnoses in psychiatry, it is important to first commit to memory the time requirements and number of symptoms. For major depressive disorder, five symptoms must be present, one of which must be either depressed mood or anhedonia (lack of Interest), for a minimum of 2 weeks. The rest of the nine possible symptoms are Sleep disturbance, feelings of worthlessness or inappropriate Guilt, lack of Energy, diminished Concentration, change in Appetite or weight, Psychomotor agitation or retardation, and Suicidal ideations. A useful mnemonic is SIG E CAPS. The vignette does not describe any history of manic episodes that could indicate bipolar disorder. If the patient had not met at least five criteria, a diagnosis of adjustment disorder could be considered as his symptoms were precipitated by a major life stressor that was initiated within 3 months of the stressor and had not persisted for more than 6 months. In dysthymic disorder, a patient exhibits a less severe form of depression on more than half of the days for a period of more than 2 years. 130 Kibble_Sec06_129-139.indd 131 4/24/13 3:34 PM A 27-year-old female medical student is brought to the emergency department by her roommate who is concerned about her lack of sleeping. The patient has not slept in 2 days and has been frantically cleaning their apartment. The roommate also states that the patient has been acting unusually promiscuous over the past week and accumulated thousands of dollars in credit card charges 6 buying new clothes. The patient states she feels great and just has not been feeling tired. Her past history is significant for one suicide attempt at 17 years after breaking up with a boyfriend. She was subsequently treated with fluoxetine for 2 years but currently takes no medications. On examination, the patient is hyperverbal with psychomotor agitation and reports that she is on the verge of discovering the cure for cancer. 131 Kibble_Sec06_129-139.indd 131 4/24/13 3:34 PM Bipolar Disorder This patient has bipolar I disorder. This diagnosis requires the presence of at least one manic episode, usually with a history indicative of one or more episodes of major depressive disorder. A manic episode consists of at least 1 week of an abnormally elevated, expansive, or irritable mood or a required hospitalization with at least three symptoms. Symptoms include distractibility, insomnia or decreased need for sleep, grandiosity (inflated self-esteem), flight of ideas (racing thoughts), psychomotor agitation or increase in goal-directed activities, pressured speech, and risk-taking (activities involving pleasure with painful consequences, i.e., excessive spending, sexual indiscretion, gambling). A useful mnemonic is DIG FAST. For bipolar I disorder, the mood disturbance must be sufficient enough to cause social or occupational impairment, requires hospitalization, or has psychotic features. If this is not the case, but at least three symptoms with mood change have been present for at least 4 days, it is considered a hypomanic episode and the diagnosis would be bipolar II disorder. It is important to distinguish the symptoms from personality disorders, as the personality disorders are reported under axis II diagnoses. 131 Kibble_Sec06_129-139.indd 132 4/24/13 3:34 PM An 11-year-old boy is brought to the pediatrician by his mother, who is concerned about his behavior. She states he has become increasingly rebellious since his parents divorced 3 years ago. He was recently suspended for making fun of a smaller classmate and his mother often receives calls from the teacher for talking back. He refuses to do his homework and is verbally abusive to 6 his mother. Physical examination reveals a slightly overweight boy, appropriately dressed with normal affect, and linear thought process without psychomotor agitation. 132 Kibble_Sec06_129-139.indd 132 4/24/13 3:34 PM Oppositional Defiant Disorder This patient is presenting with oppositional defiant disorder. This is characterized by ongoing defiant and hostile behavior toward authority figures. This differs from conduct disorder in that there are not serious violations of social norms, such as physical altercations, property destruction, animal cruelty, theft, or other activities that might rise to the level of concern to law enforcement. Conduct disorder also often progresses to antisocial personality disorder after 18 years of age. Other considerations might be separation anxiety disorder following the loss of an attachment figure in the divorce, which typically starts at around 7 to 8 years of age. 132 Kibble_Sec06_129-139.indd 133 4/24/13 3:34 PM A 36-year-old male is presented at the emergency department by the police because he was found standing on the side of the highway. The patient claims that he felt like he was unable to move and he does not remember how long he was standing there. He thinks that FBI agents have been following him for the past 6 months, and he does not feel safe at home anymore. He also admits 6 to having intermittent thoughts of committing suicide. During the interview, he mentions that his thoughts of suicide are augmented due to the voices telling him to “end it.” The patient’s past medical history is significant only for well-controlled type 2 DM. His vital signs on admission are heart rate is 78/min, respiratory rate is 16/min, blood pressure is 118/82 mm Hg, temperature is 36.7°C (98.1°F), and oxygen saturation is 99%. On further examination, the patient displays flat affect, paranoia, tangential and illogical thought processes, and disorganized speech. Urine drug screening is negative for illicit substances. 133 Kibble_Sec06_129-139.indd 133 4/24/13 3:34 PM Schizophrenia This patient meets the DSM-IV criteria for schizophrenia, which requires more than 6 months of disturbed functioning with at least 1 month of at least two of the following symptoms (unless delusions are bizarre or voices provide running commentary, then only one criterion is needed): delusions, hallucinations, disorganized behavior/catatonia, disorganized speech, and negative symptoms. These symptoms arise from a decrease in dopaminergic activity. Negative symptoms (anhedonia, flat affect, avolition) stem from the frontal cortical region, whereas positive symptoms (delusions and hallucinations) arise from the mesolimbic system. Typical treatment consists of dopamine antagonists. However, due to high incidence of tardive dyskinesia and extrapyramidal symptoms associated with D2 dopamine receptor blockade in typical antipsychotics, atypical antipsychotics are usually the first-line pharmacotherapy. 133 Kibble_Sec06_129-139.indd 134 4/24/13 3:34 PM A 23-year-old male is brought to a psychiatrist by his mother. She reports he has been behaving strangely since he graduated from college 3 months ago. He stopped socializing with his friends and now spends the entire day in his room. Upon questioning, he is reluctant to answer simple questions. He eventually reveals that God has been speaking to him and providing him instruc- 6 tions for creating a device, which will allow him to read other people’s thoughts. Examination reveals an unkempt, disheveled male with restricted affect and circumstantial thought process. Urine drug screening was negative. 134 Kibble_Sec06_129-139.indd 134 4/24/13 3:34 PM Schizophreniform Disorder This patient has schizophreniform disorder. The length of time of continuous signs of disturbance differentiates the disorders presenting with symptoms of schizophrenia. Brief psychotic disorder denotes less than 1 month of symptoms, usually related to stress. More than 1 but less than 6 months of disturbed behavior including occupational/social declines or negative symptoms including 1 month of psychotic symptoms is classified as schizophreniform disorder. Symptoms persisting for more than 6 months indicate schizophrenia. Schizophrenia criteria plus major depression, manic episodes, or both indicates a diagnosis of schizoaffective disorder. It is important to distinguish axis I disorders from the schizoid and schizotypal personality disorders that are part of axis II. 134 Kibble_Sec06_129-139.indd 135 4/24/13 3:34 PM A 34-year-old woman is being seen in the emergency department for chest pain that started 2 hours ago. She states it came on quickly and lasted less than 20 minutes. The event was accompanied by palpitations, sweating, and shortness of breath. She currently has no pain or other symptoms. Earlier in the evening she had an argument with her boyfriend. She has had one similar episode 6 in the past, but it resolved in 10 minutes and she did not seek medical attention. She takes a PPI for mild GERD. Her blood pressure is 128/78 mm Hg, pulse is 84/min, respiratory rate is 14/min, and temperature is 37.5°C (99.5°F). She has a normal S1 and S2 without additional heart sounds, murmurs, or rubs. Chest is clear to auscultation bilaterally. ECG shows a normal sinus rhythm. Chest X-ray is normal and a urine drug screening is negative. 135 Kibble_Sec06_129-139.indd 135 4/24/13 3:34 PM Panic Attack This patient has had a panic attack. Panic attacks can present with a variety of symptoms including palpitations, sweating, trembling, sensation of shortness of breath or smothering, feeling of choking, chest pain or discomfort, nausea or abdominal distress, derealization or depersonalization, fear of losing control, fear of dying, paresthesias, and chills or hot flushes. The attack must be a period of intense fear or discomfort with four or more symptoms developing abruptly and reaching a peak within 10 minutes. This should be considered in a young, healthy patient with chest pain and otherwise normal findings, particularly when accompanied by a precipitating event. In this case, the patient’s attack may have been triggered by the argument. Panic disorder is characterized by recurrent unexpected panic attacks or persistent concern of having a panic attack or its consequences. This may or may not be accompanied by agoraphobia, a fear of being in public places. Panic attacks on exposure to specific situations are characterized as a specific phobia. It is important to rule out cocaine-induced myocardial ischemia, which can be seen on ECG and urine drug panel. 135 Kibble_Sec06_129-139.indd 136 4/24/13 3:34 PM A 42-year-old woman is being seen by her primary care physician for an annual visit. Her only complaint is daytime fatigue that has been affecting her performance at work. She denies any fever, weight changes, temperature intolerance, weakness, or lightheadedness. Inquiry into sleep patterns reveals that she awakens in fear each night due to recurring dreams of being followed, 6 often with palpitations and profuse sweating. After further questioning, she tearfully admits that she was sexually assaulted in a parking garage 3 months ago. Further discussion reveals that the patient has debilitating panic attacks whenever she sees a parking garage and now avoids going out in public whenever possible. 136 Kibble_Sec06_129-139.indd 136 4/24/13 3:34 PM Posttraumatic Stress Disorder This patient has posttraumatic stress disorder (PTSD). PTSD is characterized by the exposure to a traumatic event that the person persistently re-experiences. This may be through intrusive thoughts of recollection, recurrent dreams, flashbacks, or intense responses to external cues. Patients will also have increased arousal and avoidance of stimuli associated with the event. The level of disturbance in PTSD will cause impairment of social, occupational, or other important area of functioning. In addition, like any other diagnosis in psychiatry, the condition must not be due to the effect of a substance (e.g., illicit drug, medication), medical condition, or exacerbation of a preexisting axis I (psychiatric) or axis II (personality) disorder. PTSD can present with symptoms similar to generalized anxiety disorder, so a complete history is essential. It is important to note that in patients with PTSD who have a military background, there is a high incidence of concurrent substance abuse. Therefore, it is important to screen for alcohol and drug use, and generally, BZDs are not recommended in this population. 136 Kibble_Sec06_129-139.indd 137 4/24/13 3:34 PM A 16-year-old female is brought to the gynecologist by her mother for amenorrhea. Her first menses was at 12 years of age, and she developed regular monthly cycles until about a year ago. Her last menses was 6 months ago. The patient states that she is not sexually active. Physical examination reveals a slender female, Tanner Stage V. She is 65 inches (165 cm) tall and weighs 6 104 lb (47.2 kg) with a BMI of 17.1 kg/m2. Pelvic examination is unremarkable. Skin examination shows soft, fine hair on her extremities and a small abrasion of the skin over the right third and fourth metacarpophalangeal joints. When asked about the abrasion, the patient states she scratched her hand during gymnastics practice. 137 Kibble_Sec06_129-139.indd 137 4/24/13 3:34 PM Anorexia Nervosa This patient has anorexia nervosa. To meet the DSM-IV criteria, a patient must be less than 85% of ideal body weight, but maintain a distorted impression of their body weight or shape, with an intense fear of gaining weight and 3 months of amenorrhea. Since calculating 85% of total body weight can be time consuming in the clinical setting, a BMI of less than 17.5 kg/m2 is typically used as the standard indicating an anorexic weight range. Amenorrhea in anorexia nervosa is a result of low levels of luteinizing hormone (LH) and suppression of physiologic hormone fluctuations. Lanugo (thin body hair) is one of many complications that can develop from anorexia, which can also include osteoporosis, cachexia, cardiac arrhythmias, and even sudden death. This patient’s skin abrasion is suggestive of self-induced vomiting. Anorexics may achieve and maintain their low weight through a number of methods including binging, purging (vomiting, laxative abuse, diuretics, etc.), excessive exercise, and starvation. Complications of purging can include electrolyte abnormalities (particularly hypokalemia), salivary gland enlargement, dental caries, and seizures. Patients with bulimia nervosa also binge and purge; however, they have a normal or high BMI, without such distortion in body perception. Patients may also have an isolated distorted perception of a specific part of their body, which is known as body dysmorphic disorder. 137 Kibble_Sec06_129-139.indd 138 4/24/13 3:34 PM A 57-year-old male presents to his primary care physician for follow-up on his hypertension. In addition, he notes that he is always tired and frequently falls asleep at work. He reports that he usually goes to bed around 10:30 PM and wakes up at 7:00 AM and does not have problems falling asleep or staying asleep. However, he is still very tired when his alarm clock wakes him up. He 6 takes lisinopril and hydrochlorothiazide for hypertension. His blood pressure is 158/86 mm Hg, pulse is 74/min, respiratory rate is 14/min, and temperature is 36.9°C (98.4°F). The patient’s BMI is 35 kg/m2. Physical examination shows an obese male with a mildly erythematous oropharynx, and presence of an S4 heart sound in addition to S1 and S2. 138 Kibble_Sec06_129-139.indd 138 4/24/13 3:34 PM Obstructive Sleep Apnea This patient has obstructive sleep apnea (OSA), which is characterized by functional obstruction of the upper airway for brief periods while the patient sleeps. These pauses (periods of apnea) last at least 10 seconds and often longer, leading to a decrease in arterial oxygen saturation and transient arousal from sleep. Patients are usually not aware of these disturbances while they are sleeping, but will often awake from a sufficient period of sleep without feeling refreshed and have unexplained excessive daytime sleepiness. Typically, a partner will also note that they snore loudly. OSA is generally found in individuals with obesity and is frequently associated with hypertension. Narcolepsy is much less common, but also presents with excessive daytime sleepiness and intrusion of aspects of rapid eye movement (REM) sleep into daytime wakefulness. The most common symptoms are sleep attacks, in which a patient cannot avoid falling asleep, typically leading to irresistible 10- to 20-minute periods of sleep. These can occur at very inconvenient times, such as while driving, and may include cataplexy, a sudden loss of muscle tone, that may lead to collapse from paralysis of all skeletal muscles. Other conditions that can lead to daytime sleepiness include shift work (disruption of circadian rhythms), restless leg syndrome, jet lag, and insufficient sleep. 138 Kibble_Sec06_129-139.indd 139 4/24/13 3:34 PM A 33-year-old female presents to the emergency department with acute epigastric pain. She describes the pain as sharp, constant, and unbearable. It is not associated with eating and gets worse with moving. Review of systems is also positive for headache, nausea, dizziness, dysphagia, shortness of breath, neck pain, easy bruising, and increased urinary frequency. She is afebrile, 6 and other vital signs are normal. Examination reveals a soft, nondistended abdomen with normoactive bowel sounds that is tender to percussion and palpation in all areas. There is no guarding or rebound tenderness. A review of her records shows that she was recently admitted and received a colonoscopy for intractable diarrhea. She has also had several visits over the past few years for gastroenteritis, unexplained knee pain, and a urinary tract infection. In addition, she underwent exploratory laparoscopy for menometrorrhagia and underwent diagnostic evaluation for possible multiple sclerosis. 139 Kibble_Sec06_129-139.indd 139 4/24/13 3:34 PM Somatization Disorder This patient has somatization disorder, a very specific diagnosis out of the five somatoform disorders. It entails a history of multiple physical complaints beginning before the age of 30 years and occurring over a period of years with either treatment or significant impairment in social or occupational functioning. The complaints must include four pain symptoms (related to at least four different sites or functions), two GI symptoms other than pain (e.g., nausea, vomiting, diarrhea), one sexual or reproductive symptom other than pain (e.g., sexual dysfunction, irregular menses), and one pseudoneurological symptom other than pain (e.g., impaired coordination, weakness, double vision), none of which can be explained by physical or laboratory examination. In this disorder, the symptoms are the result of unconscious psychological factors and are not intentionally produced, such as in factitious disorder, where the patient motivation is to assume the sick role, or in malingering, where external incentives such as financial gain are present. Related disorders include pain disorder, in which pain at one or more anatomical sites is the predominant focus, and conversion disorder, manifested by one or more neurologic symptoms affecting voluntary motor or sensory function. 139 Kibble_Sec06_129-139.indd 140 4/24/13 3:34 PM