Psychiatry : Beyond the Pearls

Cover
IFC
Dedication
Title page
Copyright Page
List of Contributors
Foreword
Preface
Contents
Chapter A Primer into Psychiatry
	Introduction
	Psychiatric Interview
	Mental Status Examination
	Presenting the Case and Writing a Note
	Safety
	Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)
	Psychopharmacology
	Psychotherapy
	Ethics
	Conclusion
	References
Chapter 1 - Mental Status Examination
	What are your initial thoughts, and what do you want to know to help determine a diagnosis?
	What is being evaluated by conducting an MSE?
	How do you conduct a bedside MSE with challenging patients?
	References
Chapter 2 - Defense Mechanisms
	What is the first step in evaluating this patient?
	If you suspect intentional self-injury and the use of unhealthy defense mechanisms, what elements of the history or what di...
	Are there any additional considerations?
	What defense mechanisms has this patient displayed?
	References
Chapter 3 - Neuropsychological Testing
	What are the risk factors for a stroke?
	Why was the patient sent to a rehabilitation center?
	What is neuropsychological testing?
	What can the patient’s vocation and hobbies tell us as we proceed to neuropsychological testing?
	Why is testing of emotional functioning included for a patient who has suffered a stroke?
	How are depression and anxiety screened?
	Why did the patient complete these tasks?
	What is the next step for this patient, physically?
	Why did the neuropsychologist give the patient an intelligence test?
	References
Chapter 4 - Depression
	Given this patient’s presentation, what initial diagnoses would be important to consider in a differential?
	What medical conditions are associated with depressive symptoms?
	What are some other considerations in a case like this?
	What are the treatment options for patients with major depressive disorder?
	What are the ethical considerations for involuntary hospitalization?
	References
Chapter 5 - Bipolar
	What are the first steps in evaluating the behavioral changes in this patient?
	How do you diagnose bipolar I disorder?
	What are the acute and maintenance pharmacotherapeutic treatment options for bipolar disorder?
	What are the nonpharmacotherapeutic options for treatment of bipolar disorder?
	How can lithium side effects be used to guide prevention of recurrent manic episodes?
	How can the etiology of renal dysfunction be identified as lithium-induced versus lithium-independent?
	How can pharmacogenomics be used to improve outcomes for patients with bipolar disorder?
	References
Chapter 6 - Generalized Anxiety Disorder
	What would be the first thing you would want to know to help narrow the differential diagnosis?
	After obtaining a thorough history, what tests, if any, do you need to order to rule out medical causes of anxiety in this ...
	What other laboratory tests do you want to order?
	Based on the information from the physical and laboratory workup, how has the differential changed?
	If you believe the patient has a psychiatric disorder, what information do you need to know that would help you correctly d...
	Considering the different anxiety disorders typically experienced in adults, what is the most likely diagnosis in this patient?
	What are the treatment options in a patient with generalized anxiety disorder?
	References
Chapter 7 - Panic Disorder
	What history is essential to obtain when you suspect panic attacks?
	What questions should you ask to exclude other possible diagnoses?
	What is the natural course and prognosis of panic disorder?
	What are the treatments for panic disorder?
	References
Chapter 8 - Posttraumatic Stress Disorder vs Acute Stress Disorder
	What is the first thing you would want to know about a patient presenting with sleep disturbance, nightmares, and an increa...
	In suspecting PTSD, what is an important part of the history to determine?
	Diagnosing Trauma-Induced Stress Disorders
	In consideration of this recent trauma and the symptoms this man is experiencing, what is the most likely diagnosis?
	What therapy should be recommended to this patient?
	What are the first-line medical treatments for patients with PTSD?
	References
Chapter 9 - Obsessive-Compulsive Disorder
	What would be the differential diagnosis based on the information you have?
	If you suspect an underlying anxiety disorder, eating disorder, mood disorder, or obsessive-compulsive disorder, what initi...
	What are additional considerations?
	What is the heritability of OCD?
	How is OCD diagnosed?
	What are the percentage of symptoms seen in OCD?
	What are the treatment options?
	References
Chapter 10 - Illness Anxiety Disorder/Somatic Symptom Disorder
	What additional testing would you want to get?
	What are somatoform disorders?
	What is Illness Anxiety Disorder?
	How is somatic symptom disorder different from illness anxiety disorder?
	What kind of prognosis does illness anxiety disorder have?
	What would the differential diagnosis list include?
	How would you treat this patient?
	References
Chapter 11 - Delirium
	What is your diagnosis for his change in mental status?
	What is your differential diagnosis for the cause of delirium?
	Are there any other tests you would like to order to further your workup?
	What are some of the negative short- and long-term consequences from developing delirium in the ICU?
	What steps should be taken to treat this patient’s delirium in the acute setting?
	What are the pharmacologic strategies for treating delirium?
	What about nonpharmacologic therapy?
	What type of “protocols” should be put in place to control the patient’s pain and agitation while simultaneously reducing t...
	References
Chapter 12 - Mild Neurocognitive Disorder
	What are some potential causes of forgetfulness?
	What are some risk factors for cognitive impairment?
	How do these findings guide your diagnosis?
	How is cognition assessed in the clinical setting?
	How do you score and interpret the results of the patient’s cognitive assessment?
	Does the patient have major neurocognitive disorder (dementia)?
	How do you interpret the patient’s laboratory tests?
	How do you interpret the patient’s imaging?
	What is the diagnosis?
	What treatment(s) do you recommend to the patient?
	References
Chapter 13 - Major Neurocognitive Disorders: Alzheimer Disease, Vascular Dementia, and Frontotemporal Dementia
	What is the difference between mild NCD and major NCD?
	What are activities of daily living (ADLs) and instrumental activities of daily living (IADLs)?
	What are some causes of cognitive decline?
	Beyond meeting criteria for major NCD, what other information may be helpful to clarify the diagnosis?
	Once a diagnosis of major NCD is established, what are the characteristics of the four main etiologies of NCDs?
	What is the likely etiology underlying Mr. A’s major NCD with behavioral disturbances?
	How might a brain magnetic resonance imaging (MRI) or head computed tomography (CT) help clarify the diagnosis or etiology ...
	What are nonpharmacologic management strategies for patients with major NCD?
	What are pharmacologic treatment options available for major NCDs?
	References
Chapter 14 - Major Neurocognitive Disorder: Parkinson Disease vs Lewy Body Disease
	What are causes of tremor?
	What are parkinsonian symptoms?
	How do you differentiate between medication-induced parkinsonism and neurodegenerative causes of parkinsonism?
	What are cognitive screening tests?
	What is your differential diagnosis?
	What is the diagnostic criteria for DLB?
	How is DLB similar and different from PD?
	Aside from visual hallucinations, what are some comorbid psychiatric symptoms of DLB and PD?
	What is the treatment of DLB?
	References
Chapter 15 - Alcohol Use
	Given the information the patient provided, what should be included in your differential diagnosis?
	How does alcohol use affect sleep?
	How would you classify her drinking?
	What are the components of SBIRT?
	What does the literature say about the effectiveness of SBIRT?
	What laboratory tests would you want to check in patients with at-risk drinking?
	What are some of the acute risks of alcohol intoxication?
	What could be causing this seizure?
	How do you manage alcohol withdrawal?
	Does this patient have a substance use disorder?
	What gender differences are there for AUD?
	What are some of the most significant health consequences of severe AUD?
	What are the physical findings you may find in persons with severe AUD?
	What are the components of treatment for AUD?
	What medications are effective in treating AUD?
	What are the biomarkers used to evaluate drinking in patients with AUD?
	How does alcohol affect the brain?
	What is the most likely explanation for her symptoms and how do you manage them?
	What is motivational interviewing, and how does it differ from other psychotherapeutic modalities?
	What treatment modality has been shown to be effective for individuals with co-occurring AUD and PTSD?
	References
Chapter 16 - Substance Use Disorders
	What is the prevalence of substance use disorders in older adults?
	Why are SUDs underdiagnosed in older adults?
	In general, when should you consider substance use disorders as a diagnosis?
	How do you screen for substance use disorders in the older adult?
	What is a brief intervention that can be performed in the office to reduce patient risk?
	How is a diagnosis of substance use disorder established?
	What complications of opioid use should be screened for in this patient?
	How do you recognize and treat withdrawal?
	What are the different settings for treatment of substance use disorders in older adults?
	What psychosocial treatments are available?
	What is medication-assisted therapy (MAT)?
	References
Chapter 17 - Cluster A Personality Disorders
	What is the initial differential diagnosis based on this information?
	Is taking a developmental history appropriate?
	What questions should this patient be asked?
	How has the differential diagnosis changed?
	What is the diagnosis, and what are the deciding factors?
	Why is it important to ask his sister additional questions?
	What is the development, course, and prognosis of schizoid personality disorder?
	How does schizoid personality disorder compare to paranoid personality disorder?
	How does schizoid personality compare to schizotypal personality disorder?
	What are some other commonalities between the cluster A personality disorders?
	Are there any other nonpersonality disorder psychiatric disorders to consider?
	References
Chapter 18 - Cluster B Personality Disorders
	What is the first step in evaluating this patient?
	What is the differential diagnosis?
	What are additional considerations for this patient?
	References
Chapter 19 - Cluster C Personality Disorders
	What other information is important to know?
	You suspect the patient is suffering from obsessive-compulsive personality disorder; what other questions should be asked t...
	How is obsessive-compulsive personality disorder distinguished from obsessive-compulsive disorder (see Table 19.1)?
	What are the treatment options for OCPD?
	What are the most common defense mechanisms used in obsessive-compulsive personality disorder that can be addressed in ther...
	What are the other cluster C personality disorders and how would you diagnose and treat them?
	What is the cause of cluster C personality disorders?
	How can you differentiate avoidant personality disorder from schizoid personality disorder?
	References
Chapter 20 - Eating Disorders
	How do you diagnose anorexia nervosa?
	What is on your differential diagnosis?
	What are the common findings on a physical examination?
	What are the medical complications of anorexia nervosa?
	What laboratory workup should you order?
	How do you treat anorexia nervosa?
	When do you consider inpatient medical or psychiatric hospitalization?
	What is your diagnosis?
	How do you prevent and treat a refeeding syndrome?
	What are the basic principles of cognitive behavioral therapy (CBT) for eating disorders?
	References
Chapter 21 - Schizophrenia vs Brief vs Schizophreniform
	What additional information would you like to know about this patient?
	If the patient’s urine drug screen is positive for substance abuse, does that change your evaluation or treatment considera...
	What symptoms does this patient have that suggest a psychotic condition?
	What about this patient’s presentation would suggest a diagnosis of a primary psychiatric illness?
	DSM-5 Diagnostic Criteria for Schizophrenia
		If you suspect a diagnosis of schizophrenia, what elements of the history would be good versus poor prognostic indicators?
		The patient had expressed that he did not want to be hospitalized. What about this patient’s presentation allowed him to be...
		What are some treatment challenges when treating a patient with a suspected diagnosis of schizophrenia?
	References
Chapter 22 - Schizoaffective, Delusional Disorder
	What initial differential diagnoses would be important to consider given this patient’s symptom history?
	What diagnostic tests will you need to order to determine the etiology of this patient’s psychosis?
	Based on the results of the laboratory workup, how has the differential diagnosis changed?
	If this patient has a suspected psychiatric disorder, what elements from the history will be critical in establishing a mor...
	Considering the broad differential for psychiatric disorders, what is the most appropriate diagnosis for this patient?
	What are the ethical and legal factors involved in hospitalizing a patient with a psychiatric condition?
	What are common pharmacologic and therapeutic options for treatment of schizoaffective disorder?
	References
Chapter 23 - Attention Deficit Hyperactivity Disorder
	What is attention deficit hyperactivity disorder (ADHD)?
	What is relevant to a diagnosis of ADHD from this history?
	The girl’s mother has both ADHD and major depressive disorder. How common are comorbidities in ADHD?
	What is your diagnosis?
	What medications are used to treat ADHD?
	What are the nonpharmacological treatments for ADHD?
	References
Chapter 24 - Autism Spectrum Disorder
	What are the developmental milestones?
	So far, what is your differential diagnosis?
	What is the M-CHAT?
	What is autism spectrum disorder?
	What are the risk factors for ASD?
	How useful is genetic testing in ASD?
	References
Chapter 25 - Impulse Control and Conduct Disorders
	What are disruptive, impulse-control, and conduct disorders?
	What are the symptoms of oppositional defiant disorder (ODD)?
	How common is ODD?
	What are the risk factors of ODD?
	Does this boy have intermittent explosive disorder (IED)?
	What are the symptoms of conduct disorder (CD)?
	What distinguishes CD from ODD?
	What are the suggested assessment tools for disruptive, impulse-control, and conduct disorders?
	What is your differential diagnosis for this patient?
	What is the treatment for ODD?
	References
Chapter 26 - Tic Disorders and Tourette Syndrome
	What is a tic?
	How are tics categorized?
	What is your differential diagnosis?
	The family asks for additional testing or imaging. What do you tell them?
	What are your initial treatment considerations?
	What psychotherapy modalities are effective for Tourette syndrome?
	What is your diagnosis?
	What is the pathophysiology of Tourette syndrome?
	What is the natural course and prognosis of Tourette disorder?
	What are the common psychiatric comorbidities of Tourette syndrome?
	How do you counsel them?
	What treatment options would you offer at this time?
	What is PANDAS?
	What are the complications of tic disorders?
	References
Chapter 27 - Dissociative Disorders
	What is your initial differential diagnosis?
	What is important to include in your interview and to assess on mental status examination?
	How has your differential diagnosis changed based on your examination and these results?
	What is your psychiatric differential diagnosis?
	What is the diagnosis?
	What are risk factors for dissociative amnesia and dissociative fugue?
	What is the course and prognosis of dissociative amnesia?
	What distinguishes dissociative amnesia from dissociative identity disorder?
	What are associated features of individuals with DID?
	What is your differential diagnosis?
	What questions do you want to ask this patient?
	What is your diagnosis?
	What are the risk factors for dissociative disorders?
	What substances may cause dissociative symptoms and apparent memory loss?
	What is the treatment for dissociative disorders?
	References
Chapter 28 - Narcolepsy
	What is on the differential diagnosis?
	How does this information change the differential diagnosis?
	What features are suggestive of narcolepsy?
	What are diagnostic tests or evaluations that may be ordered?
	Does the sleep test result help in diagnosis?
	Is there an additional test that may be helpful?
	What is the diagnostic criteria for narcolepsy?
	What are treatment options?
	References
Chapter 29 - Insomnia
	What is on the differential diagnosis?
	What psychiatric disorders can present with sleep dysfunction?
	What other diagnoses could be explored?
	What are first-line treatments for insomnia with the highest evidence rating?
	Which medications are to be avoided in this patient?
	Which medications can be considered for this patient?
	References
Chapter 30 - Parasomnias
	What is your differential diagnosis for this patient’s abnormal behavior at night?
	What additional diagnostic testing would you order to further evaluate this patient’s complaint and to distinguish between ...
	What are the main findings in PSG in cases of NREM parasomnias?
	After performing the PSG, what is the most likely explanation of the patient’s complaints?
	References
Chapter 31 - Obstructive Sleep Apnea
	What is the most likely diagnosis? What clues in the patient’s history reinforce this diagnosis?
	What are the changes in sleep respiratory physiology that predispose a patient to OSA?
	What additional diagnostic tests would you need to complete to confirm a diagnosis of OSA?
	What are some common causes of central sleep apnea?
	References
Chapter 32 - Gender Dysphoria
	What is gender identity?
	How is gender identity different from sexual orientation?
	What cultural considerations should health care providers keep in mind when working with transgender patients?
	What is the differential diagnosis?
	Does this patient have transvestic disorder?
	Does this patient have body dysmorphic disorder?
	Does she have a psychotic disorder?
	What is gender dysphoria (GD)?
	Does this patient have GD?
	What is the treatment for GD?
	How common is comorbid mental illness in transgender patients?
	What is your differential diagnosis for this patent’s anxiety?
	What is social anxiety disorder?
	References
Chapter 33 - Paraphilias
	What are possible causes for these symptoms?
	What is a paraphilia?
	What is a paraphilic disorder?
	Does he have a paraphilia?
	Does he have a paraphilic disorder?
	His mother is concerned about voyeurism, exhibitionism, or frotteurism. Does his history indicate any of these behaviors?
	Does he have sexual masochism disorder?
	He is 19 years old and his boyfriend is under 18 years old. Does he have pedophilic disorder?
	What is the diagnosis?
	What are the available treatments for paraphilic disorders?
	References
Chapter 34 - Neuroleptic Malignant Syndrome
	What is your initial differential diagnosis?
	What is your initial approach with this patient? What labs would you like to order?
	Does this change your differential diagnosis?
	Are there any medications or treatments you would like to start?
	Can you confirm a diagnosis of neuroleptic malignant syndrome on the indicated findings?
	What further management is warranted based on this workup?
	How common is NMS? What is the typical presentation, diagnostic criteria, and duration?
	What is the underlying pathophysiology?
	How can you distinguish NMS clinically from other etiologies with similar presentations?
	What other management strategies have been suggested for severe cases? Can neuroleptic medications be administered after re...
	References
Chapter 35 - Serotonin Syndrome
	What are some causes of altered mental status?
	In general, when should you consider toxidrome as a diagnosis?
	How do you distinguish the particular toxidrome as the etiology of this patient’s presentation?
	What is your differential diagnosis?
	What is Serotonin Syndrome?
	What are the clinical manifestations of serotonin syndrome?
	How does linezolid cause serotonin syndrome?
	What is the treatment for serotonin syndrome?
	References
Chapter 36 - Lithium Toxicity
	What other information do you want to know?
	If you suspect lithium toxicity, what laboratory or other diagnostic testing should be ordered?
	What are the most important signs and symptoms of lithium toxicity?
	What are the most important aspects of lithium toxicity treatment?
	Why do lithium levels sometimes increase again even after they have started to decrease with one session of hemodialysis?
	How is lithium absorbed, metabolized, and excreted?
	What are some long-term side effects of lithium use?
	References
Chapter 37 - Suicide Risk Assessment
	What is the definition of suicide?
	What is a suicide risk assessment?
	Who can perform a suicide risk assessment?
	Which patients require a suicide risk assessment?
	What are some common static risk factors for completed suicide?
	What are some common dynamic risk factors for completed suicide?
	Are there any protective factors against suicide?
	What is the link between firearms access and suicidality?
	What is this patient’s suicide risk?
	If this patient’s risk for acute suicide was elevated, what are some evidence-based interventions that decrease suicide risk?
	What can be done if you suspect a patient to have elevated risk for acute suicide?
	References
Chapter 38 - Medication-Induced Movement Disorders
	What are medication-induced movement disorders?
	What is the differential diagnosis for this patient?
	What is the treatment for acute dystonia?
	What is akathisia?
	What are treatments for akathisia?
	What is galactorrhea and why is the patient experiencing this?
	What are the risks and benefits of long-acting injectable antipsychotic medications?
	What is tardive dyskinesia (TD)?
	Dopamine is needed in the substantia nigra to initiate movement. Why would long-term dopamine blockade lead to hyperkinetic...
	What is a scale that can be helpful in monitoring for signs of TD?
	What are treatments for tardive dyskinesia?
	References
Chapter 39 - Alcohol Withdrawal
	What significant medical history are you suspicious for given his physical examination and laboratory findings?
	What do you think has caused this acute change in mental status?
	What other diagnoses should be considered?
	What causes alcohol withdrawal symptoms?
	Once the diagnosis of alcohol withdrawal is established, what is your priority in treating this patient?
	What should you anticipate as you continue to manage this patient?
	What is the mainstay of medical treatment for alcohol withdrawal?
	How do we know how much benzodiazepine to give?
	What is the next best step in his care?
	Are there other adjunctive treatments to consider?
	What should you do now?
	Should you change your treatment plan for his alcohol withdrawal now that he is intubated?
	What is the normal time course for alcohol withdrawal resolution?
	References
Index
IBC