Consultation-Liaison Psychiatry: Leslie M. Forman, M.D., Neil Scheurich, M.D., and Kristen Tyszkowski, M.D

Consultation-Liaison
Psychiatry
Leslie M. Forman, M.D., Neil Scheurich, M.D., and Kristen Tyszkowski, M.D.
Contents
1. Introduction 14. Somatoform Disorders
2. Anxiety and Medical Conditions 15. Somatization Disorder
3. Depression and Medical Conditions 16. Undifferentiated Somatoform

Disorder
4. Delirium
17. Conversion Disorder
5. Personality Disorders and Medical
Conditions 18. Pain Disorder
6. Personality Change Due to a General 19. Hypochondriasis

Medical Condition
20. Body Dysmorphic Disorder
7. Psychotic Disorders
21. Somatoform Disorder Not
8. Chronic Pain Otherwise Specified
9. Psychopharmacology in the Medically 22. Psychological Factors Affecting

Ill (or Pregnant) Patient Medical Condition
10. Transplantation Issues 23. Factitious Disorders
11. Medical Illness Presenting With 24. A Note on Malingering

Psychiatric Symptoms
25. Legal Issues
12. Neuropsychiatric Manifestations
of HIV 26. Questions
13. Drug Intoxication and Overdose 27. References
CONSULTATION-LIAISON PSYCHIATRY 1
1. Introduction
Patients with serious medical illnesses and coexisting A consultation note should include all of the above
behavioral disorders present a challenge to the psychi- information, with a diagnostic formulation. If possi-
atric consultant. To determine the likely cause of a ble, the etiology of a behavioral disturbance should
behavioral disturbance, the psychiatrist must be famil- be noted, or a list of possible etiologies should be
iar with the behavioral manifestations of medical ill- outlined (eg, “delirium due to alcohol withdrawal,
ness and the behavioral side effects of medical drugs, rule out head injury”). Recommendations should
in addition to having the usual expertise in purely psy- then be made, including further testing to clarify the
chiatric disorders. The consultant should have an diagnosis, and management strategies (such as psy-
understanding of common (and not so common) drug chotropic medications, psychotherapy, or sugges-
interactions which could cause behavioral distur- tions to the staff for effective management of the
bances, as well as interactions with psychotropic patient on the ward). Recommendations should be as
drugs that could be potentially dangerous, and side specific and detailed as possible. Finally, when indi-
effects of psychotropic medications which could cated, recommendations for postdischarge follow-up
cause worsening of a patient’s medical condition. can be made.
Thus, the knowledge base in consultation-liaison psy-
chiatry is broad.
Formal Consultation
A consultation begins with a question from a referring

physician. Often, this will be vague (“please evaluate
depression”), and talking with the referring physician
before the consultation is begun can be valuable. The
next step is to review the complete medical record for
the hospitalization, including chief complaint, history
of present illness, physical examination, review of
systems, past medical and psychiatric history, social
history, family history, history of alcohol and sub-
stance abuse, allergies, hospital course (by reviewing
progress notes), laboratory results, and medications
ordered and, in the case of PRNs, medications
received. The staff may be consulted to clarify any
confusing issues in the chart.
Next, the patient is interviewed at the bedside. In cases

such as delirium or drug overdose, the patient may not
be able to respond adequately to questioning and the
family or other informants should be sought out.
When the patient is capable of responding to ques-
tions, the consultant should obtain a thorough psychi-
atric history and mental status examination, and clar-
ify any points which may be unclear in the medical
record, depending on the alertness of the patient. In
patients with suspected conversion disorder or chronic
pain, a focused physical or neurologic examination
may be done.
2 EDUCATIONAL REVIEW MANUAL IN PSYCHIATRY

2. Anxiety and Medical Conditions
Compared with mood disorders, anxiety disorders articulate the sense of doom or terror that, by defini-
in the medical setting (with the exception of panic tion, accompanies a panic attack. Individuals with
disorder) have received little attention. Because panic disorder may have comorbid angina and simi-
anxiety can be expected to accompany the experi- lar conditions as well, which complicates the evalua-
ence of confronting a major illness, especially in a tion. Panic disorder was long held to be correlated
hospital, it can be difficult to articulate adequately with mitral valve prolapse, but reexamination of epi-
the point at which anxiety goes from being a symp- demiologic data has cast doubt upon that association.
tom to being a disorder. The medical differential diagnosis of panic disorder
includes asthma, pulmonary embolus, myocardial
Anxiety may complicate a medical evaluation in the infarction, complex partial seizures, pheochromocy-
form of specific phobias about diagnostic procedures, toma, caffeinism, hypoglycemia, hyperthyroidism,
such as biopsies or the potentially claustrophobic hyperparathyroidism, vestibular dysfunction, car-
experience of being inside a magnetic resonance diac arrhythmias, substance abuse (both intoxication
imaging (MRI) scanner. Support and reassurance, and withdrawal), and medication side effects.
cognitive-behavioral strategies, and use of short-term
benzodiazepine may be helpful. Alternatively, trau- In general, by the time patients with panic disorder see
matic experiences such as chemotherapy and major a psychiatrist, they have often had a medical work-up.
operations can engender posttraumatic stress disorder However, some clues suggest panic disorder in
in susceptible individuals. ambiguous cases. Patients with panic disorder often
have agoraphobia or multiple phobias. They may have
Numerous medical conditions may cause or masquer- somatic preoccupation and make frequent emergency
ade as anxiety. A partial list of such includes the fol- room visits. They may report increased sensitivity to
lowing: Cushing’s disease, Addison’s disease, carci- stimulants such as caffeine, and may have drug or
noid syndrome, hyperthyroidism, hypoglycemia, alcohol abuse in an attempt at self-medication. True
pheochromocytoma, anemia, hypoxia, angina pec- loss of consciousness is less likely than in some medi-
toris, arrhythmias, asthma, pneumothorax, pulmonary cal disorders (eg, seizures).
embolus, systemic lupus erythematosus, acute inter-
mittent porphyria, brain tumor, and multiple sclerosis. Treatment of anxiety disorders in the context of medi-
cal illness is analogous to the treatment of anxiety in
Many medications may give rise to anxiety symp- general, which is detailed elsewhere in this volume.
toms: aspirin and other nonsteroidal anti-inflamma-
tory drugs (NSAIDs), caffeine, steroids, nicotinic
acid, bronchodilators, insulin, thyroxin, estrogen, lev-
odopa, and digoxin. Dopamine blockers such as meta-
clopramide, promethazine, prochlorperazine, and
antipsychotics can cause akathisia, which may be mis-
taken for anxiety.
Panic disorder probably is the most recognized anxi-

ety disorder in the medical setting because it mimics
several potentially catastrophic medical conditions.
Symptoms of a panic attack can be similar to those of
a fatal arrhythmia, myocardial infarction, pulmonary
embolus, or stroke. Individuals with panic disorder
have been estimated to constitute a significant
minority of patients in emergency rooms and critical
care units. Such persons often go undiagnosed for
years, while utilizing large numbers of diagnostic
tests and medical resources. Evaluation can be com-
plicated by the fact that some patients are not able to
3. Depression and Medical
Conditions
Depression can be difficult to diagnose in medically The treatment of depression in the medically ill is
ill patients inasmuch as symptoms such as fatigue, not fundamentally different from the treatment of
anorexia, and insomnia may be viewed as stemming depression in general. Stress reduction, supportive
directly from a medical illness. Particular attention psychotherapy, and patient support groups may be
to such factors as disabling dysphoria or anhedonia, helpful. Cognitive behavior therapy or interpersonal
frequent crying spells, marked guilt, sense of worth- therapy may be helpful. Regarding antidepressant
lessness, feelings of hopelessness, and suicidal treatment, special attention to side effects and drug
ideation may more strongly point to the presence of interactions is necessary. Selective serotonin reup-
depression. take inhibitors (SSRIs) have generally become the
first-line agents for treatment of depression in medi-
Depression is common in many, although not all, cal populations, as they appear to have relatively few
chronic medical illnesses. It is usually difficult, if not cardiovascular and other side effects as compared
impossible, to know when a mood disorder is “due to” with older agents. Numerous trials have demon-
a medical condition and when it merely coexists; in strated stimulants to be helpful in treating depres-
practical terms, the diagnosis and treatment are the sion in the medically ill, particularly when apathy
same. The lifetime prevalence of depression in individ- and psychomotor retardation are prominent and dis-
uals with Parkinson’s disease and Huntington’s disease abling symptoms. For example, methylphenidate
is approximately 40%. A similar prevalence holds true has been used successfully for depression associ-
after a stroke, with left-sided frontal lobe strokes being ated with acquired immunodeficiency virus (AIDS)
most likely to be followed by depression. Much atten- as well as stroke. Contrary to popular belief, stimu-
tion has been paid to the pathologic euphoria that lants in typical doses tend to be well tolerated in the
rarely accompanies multiple sclerosis, but depression medically ill, rarely causing significant tachycardia
actually is much more commonly associated with that or hypertension. Paradoxically, they not only do not
condition. Some 30% to 50% of sufferers of exacerbate anorexia, but often ameliorate it. Stimu-
Alzheimer’s disease become depressed. Coronary lant abuse has been conclusively shown to be rare in
artery disease is accompanied by a 25% lifetime risk of medically ill individuals who do not have a history
depression. The prevalence of depression in cancer of substance abuse. Methylphenidate (used much
patients has been quoted from 5% to 50%, depending more commonly than dextroamphetamine, which
upon the type, location, and severity of neoplasm. carries more stigma) may be initiated at 5 mg once
Depression notoriously heralds pancreatic cancer, at or twice per day and, with monitoring of vital signs,
times months or years in advance, such that it may advanced as needed to average doses of 30 to 40
even represent a kind of paraneoplastic syndrome. mg/day. Finally, when a complete evaluation is done
and appropriate precautions are taken, electrocon-
Because almost any systemic illness or neurologic vulsive therapy (ECT) can be a safe and effective
disease may produce depressive symptoms, it is treatment for depression in the medically ill, includ-
important to treat organic illnesses first. The apparent ing the elderly and individuals with epilepsy or car-
apathy of delirium sometimes is misdiagnosed as diac disease.
depression. In elderly patients, dementia may be mis-
taken for depression, and vice versa, as in the so- A growing number of studies have demonstrated that
called pseudodementia; depression and dementia also untreated depression has deleterious effects on the
naturally may coexist. A careful history and mental course of medical illnesses. Clinically significant
status examination are necessary to differentiate them. depression—as opposed to the existential sadness and
anger that also accompany illness—should be treated
A host of medications have been known to produce aggressively, and not dismissed as “appropriate” or
depressive symptoms. A partial list includes: “to be expected.”
methyldopa, propranolol, clonidine, thiazide
diuretics, digoxin, levodopa, oral contraceptives,
glucocorticoids, benzodiazepines, cimetidine, rani-
tidine, cyclosporine, NSAIDs, sulfonamides, and
metoclopramide.

Diagnostic Issues The second problem faced by consultants is the issue
of “reactivity,” or the practice of considering depres-
Depression is one of the most common disorders sion to be a normal response to a catastrophic medical
seen in consultation psychiatry, but the accurate illness. The answer here is straightforward: the pres-
diagnosis of depression is complicated by the presence of a precipitant, medical or otherwise, in the con-
ence of medical illness in two ways. First, medical text of major depression does not affect the diagnosis
illness or medications may cause symptoms similar or response to treatment. Treatment should not be
to those seen in major depression: for example, sleep withheld from depressed patients simply because the
disturbances (too little or too much), poor appetite, patient, consultant, or medical team thinks it is logical
loss of energy, increased fatigue, and difficulty con- that a person could get depressed under these circum-
centrating. The consultant must decide whether to stances. Understanding the source of pain does not
include such symptoms when assessing the presence eliminate the need to treat it.
of diagnostic criteria for a major depressive episode.
The second problem in diagnosing clinically signifi-
cant depression in the medically ill derives from the
idea that in certain circumstances (eg, a devastating
illness such as stroke or cancer), depression is a nor-
mal, expected outcome, reactive in nature, and there-
fore requiring less attention, or a different sort of
attention, than would be focused on major depres-
sion without an obvious precipitant.
In the first instance, four approaches have been

described for dealing with the overlap of symptoms
in depression and medical illness: exclusive, inclu-
sive, substitutive, and etiologic. In the exclusive
approach, the consultant does not include in the
diagnosis of depression any symptoms that could be
caused by the medical illness. This makes it much
more difficult to make a diagnosis of depression, but
may be useful for research studies where false-posi-
tive diagnoses can be minimized. The inclusive
approach is the opposite: all symptoms are included
in diagnosing depression, whatever their cause. This
approach reduces the likelihood of missing patients
who are depressed, but probably overdiagnoses
depression. It may be more useful in clinical set-
tings, where missing a depression can have serious
repercussions. The substitutive approach omits
diagnostic criteria which are of uncertain origin,
replacing them with so-called “cognitive” symp-
toms such as indecisiveness, self-pity, brooding, or
pessimism. The etiologic approach requires the con-
sultant to decide whether the symptom is due to
depression or not. This decision can be very difficult
and the validity and reliability may not be high.
4. Delirium
Epidemiology Assessment
Delirium is estimated to occur in approximately 15% There are two stages involved in the assessment of the
of hospitalized patients, but the rates vary based on a patient with delirium. The first step is to determine
number of factors. Delirium is more common in whether the patient is delirious. This is generally
elderly patients (up to 30%), with prevalence increas- straightforward in the case of severe delirium, but is
ing with advancing age; in patients who have had cer- more difficult in the patient with mild-to-moderate
tain surgical procedures (30% in postcoronary artery delirium, particularly when that delirium is superim-
bypass patients, 50% in posthip surgery patients); and posed on a preexisting dementia (as is often the case).
in patients with preexisting dementia. In addition, the A history of a relatively acute onset of cognitive
presence of delirium correlates with poorer outcomes: decline (involving hours or at most a few days), confu-
patients who develop delirium have a higher mortality sion, and/or perceptual disturbances such as halluci-
rate—up to 25%. Patients with delirium also have nations, can usually be obtained from staff or family.
higher medical utilization, longer lengths of stay, Likewise, staff or family can usually document a fluc-
more complications after surgery, and are more likely tuating course: they will tell you, for example, that the
to develop persistent cognitive impairment, and suffer patient was better yesterday morning, became more
increased functional impairment. confused in the afternoon, by this morning was some-
what better, but later today started to hallucinate again
Diagnosis and became agitated.
According to DSM-IV, the diagnosis of delirium Examination of the patient will reveal the character-
requires: istic clouding of consciousness and cognitive
deficits. The patient may demonstrate difficulty
A. Disturbance in consciousness (ie, reduced clarity maintaining attention for a simple conversation over
of awareness of the environment) with reduced several minutes by asking the examiner to repeat
ability to focus, sustain, or shift attention. questions or by appearing confused and unable to
follow the flow of the discussion. Bedside testing of
B. A change in cognition (such as memory deficit, attention will usually reveal more subtle cases. The
disorientation, language disturbance) or the questioning should be targeted to the patient’s pre-
development of a perceptual disturbance that is sumed premorbid education level and cognitive
not better accounted for by a preexisting, estab- ability. Serial 7 subtractions can detect subtle
lished, or evolving dementia. deficits, but this test may be difficult for some
patients who are cognitively intact. Comparatively
C. The disturbance develops over a short period of easier tests of attention, such as spelling ‘world’
time (usually hours to days) and tends to fluctuate backwards, reciting the months of the year or the
during the course of the day. days of the week in reverse, immediate recall of dig-
its forwards and backwards, or doing the Trails A
D. There is evidence from the history, physical and B tests can demonstrate milder cases of
examination, or laboratory findings that the dis- impaired attention. Patients with difficulty commu-
turbance is caused by the direct physiologic con- nicating verbally (eg, intubated patients) can be
sequences of a general medical condition. asked to raise a finger whenever a certain letter is
mentioned in a long series of letters, or whenever
In addition, the diagnosis requires an attempt to deter- they hear a word in a long list that rhymes with
mine the etiology (“delirium due to...”). The diagnosis “tree.” Disorientation, constructional apraxia (eg,
may be remembered by the four Cs: consciousness, poor clock or figure drawing), and memory deficits
cognition and perception, course, and consequence of. (eg, difficulty remembering three unrelated words in
Of these criteria, impairment of consciousness is the 5 minutes) are also commonly elicited. Using the
key element.

Mini-Mental State Examination will demonstrate Table 1
specific deficiencies. Patients may reveal hallucina-
tions, misperceptions, or delusions on questioning, “WHHHHIIMP”
or staff or family can supply this information.
Once it has been established that the patient is deliri- Withdrawal or Wernicke’s encephalopathy
ous, the search for the etiology begins. There may be
Hypoxemia
multiple possible causes, and the consultant should
endeavor to make recommendations based on the Hypoperfusion
most likely choices. Some causes of delirium require
Hypoglycemia
urgent attention. They can be reviewed by the
mnemonic “WHHHHIIMP”: Hypertensive encephalopathy
Intracranial bleeding or infection
Meningitis or encephalitis
Poisons or medications
From: Wise and Rundell. Concise Guide to Consultation

Psychiatry, Second Edition.
Table 2
Other Causes of Delirium Can be Reviewed Using the Mnemonic “I WATCH DEATH”
Infection Encephalitis, meningitis, syphilis, human immunodeficiency virus, sepsis
Withdrawal Alcohol, barbiturates, sedative-hypnotics
Acute metabolic Acidosis, alkalosis, electrolyte disturbance, hepatic or renal failure
Trauma Closed-head injury, heatstroke, postoperative, severe burns
Central nervous system Abscess, hemorrhage, hydrocephalus, subdural hematoma,

pathology infection, seizures, stroke, tumors, metastases, vasculitis
Hypoxia Anemia, CO poisoning, hypotension, pulmonary or cardiac failure
Deficiencies Vitamin B12, folate, niacin, thiamine
Endocrinopathies Hyper-/hypoadrenocorticism, hyper-/hypoglycemia, myxedema,

hyperparathyroidism
Acute vascular Hypertensive encephalopathy, stroke, arrhythmia, shock
Toxins or drugs Medications, illicit drugs, pesticides, solven
Heavy metals Lead, manganese, mercury
From APA textbook of Consultation-Liaison Psychiatry.
Almost any medication can cause delirium in a sus- Treatment
ceptible patient (Tables 2 and 3). Probably the most
common offenders are those medications with anti- The treatment of delirium begins with identifying the
cholinergic or sedative effects. Urinary tract infec- cause or causes and doing something about it—for
tions, pneumonia, and congestive heart failure are also example, treating the urinary tract infection, discon-
common causes. tinuing the offending medication, treating the conges-
tive heart failure, or relieving the pressure from a sub-
Delirious patients may be hyperactive and agitated, dural hematoma. Sometimes, this cannot be done
hypoactive, or fluctuate between the two. Perhaps the expeditiously, as when an antibiotic is causing delir-
most common reason for calling in a psychiatry con- ium but is essential for the patient’s treatment, or nar-
sultant for a delirious patient is for agitation. In this cotics are necessary for controlling severe pain. All
case, the patient may be pulling out intravenous lines, drugs which are not essential should be discontinued.
trying to get out of bed and leave the hospital, or fight-
ing with staff because of confusion, threatening delu- Whether the cause can be ameliorated or not, symp-
sions, or hallucinations. This can pose a potentially tomatic treatment is usually indicated. Documented as
serious threat to the safety of the patient and requires effective for hyperactive, and to a lesser extent for
rapid assessment and treatment. Patients may also be hypoactive, delirium, intravenous haloperidol is the
hypoactive. They may lie quietly in bed, show no mainstay of treatment. Although the intravenous
interest in surroundings, eat poorly, and be difficult to administration of haloperidol is not approved by the
engage in rehabilitation. A consultation for these Food and Drug Administration, intravenous
patients is often for evaluation of depression, but a haloperidol is generally safe and effective in control-
careful mental status examination reveals the charac- ling symptoms such as agitation, psychotic symp-
teristic cognitive pattern of delirium. Some patients toms, and mental confusion. For reasons which are
may show elements of both hyper- and hypoactivity. unclear, extrapyramidal side effects are uncommon
when haloperidol is given intravenously, even in
In certain metabolic derangements, such as hepatic very high doses. For elderly patients, dosing is
encephalopathy, characteristic physical findings such started low (eg, 0.5 mg) and doses may be given
as asterixis may be elicited. In alcohol or benzodi- approximately every 30 minutes until the patient is
azepine withdrawal states, autonomic hyperactivity calm. Higher doses are necessary (eg, 5 to 10 mg) in
(increased pulse and blood pressure, diaphoresis, agi- patients with more severe symptoms or in younger
tation) will be present. patients. Starting low and increasing the dose, if
needed, is a good strategy. Using the intravenous
Laboratory tests may include complete blood count, route, a dose of several hundred milligrams per day
chemistries, drug levels, arterial blood gases, urinaly- has been given without serious adverse effects, but
sis, electrocardiogram, and chest radiograph. An elec- this is unusual, and may lead to cardiac arrhythmia.
troencephalogram (EEG), computed tomography The presence of heparin or phenytoin can precipitate
scan, lumbar puncture, or, B12 and folate levels, or a haloperidol in the intravenous catheter; in these
heavy metal screen may be considered. cases, the catheter should be flushed with normal
saline before administration of haloperidol.
In difficult cases, an EEG may be helpful in confirm-
ing the diagnosis. In most cases of delirium, the EEG Although uncommon, intravenous haloperidol (and
shows generalized slowing. An exception is in alcohol other antipsychotics) may cause ventricular arrhyth-
withdrawal (delirium tremens), when the EEG shows mias such as torsades de pointes. Susceptible individ-
low-voltage fast waves. In hepatic encephalopathy, uals may be those with a preexisting prolonged QTc
there may be triphasic waves. interval, low magnesium or potassium, liver failure, or
certain cardiac conditions, such as mitral valve pro-
lapse or dilated ventricle. These factors should be
assessed before initiating treatment, and the QTc inter-
val can be followed once treatment is under way.

Table 3
Medications Which May be Associated with Delirium
Acetylcholinesterase Inhibitors Disulfiram Phenylephrine

ACTH Dopamine Phenylpropanolamine
Acyclovir Ephedrine Phenytoin
Amantadine Ergotamine Podophyllin (topical)
Aminoglycosides Ethambutal Procainamide
Aminophylline Fluorouracil Procarbazine
Amodiaquine Fluoxetine Propranolol
Amphetamine Gentamicin Quinacrine
Amphotericin B Hexamethylamine Quinidine
Atropine Ibuprofen Ranitidine
Azacitidine Indomethacin Reserpine
Baclofen Interferon Rifampin
Barbiturates Interleukin-2 Salicylate
Benzodiazepines Isoniazid Scopolamine
Benztropine L-asparaginase Steroids
Biperiden Levodopa Sulfonamides
Bromocriptine Lidocaine Sulindac
Bupropion Lithium Tamoxifen
Captopril Lorazepam Tetracyclines
Cephalexin Mefloquine Theophylline
Cephalosporins Meperidine Thioridazine
Chloramphenicol Methenamine Ticarcillin
Chloroquine Methotrexate Timolol
Cimetidine Methyldopa Tobramycin
Clonidine Metrimazide Tocainide
Colistin Mexiletine Tricyclic antidepressants
Cyclobenzaprine Midazolam Trihexyphenidyl
Cyclosporine Monoamine oxidase inhibitors Vancomycin
Cytosine arabinoside Naproxen Valproate
Dacarbazine Narcotic analgesics Verapamil
Digitalis Nonsteroidal anti-inflammatory Vinblastine
Disopropamide drugs Vincristine
Dipapanone Pentazocine Zolpidem
Disopyramide Phenylbutazone
Adapted from Cassem. Massachusetts General Hospital Handbook of General Hospital Psychiatry. Third Edition;
Cassem, et al. Massachusetts General Hospital Handbook of General Hospital Psychiatry. Fourth Edition.
Other antipsychotic drugs have side effect profiles The concept of “ICU psychosis,” that is, psychotic
less favorable and are rarely recommended. Recent symptoms or confusion brought on by the sensory
studies suggest that the newer atypical antipsy- deprivation or confusion associated with a stay in the
chotics may be effective when oral dosing is possi- ICU, has largely been discredited. When a patient in
ble. For treating delirium related to alcohol or ben- the ICU develops delirium, a search for specific
zodiazepine withdrawal, treatment with benzodi- causes must be undertaken rather than simply attribut-
azepines is indicated. ing the delirium to the effects of being in the ICU.
Some authorities recommend treating delirium with

concurrent intravenous dosing of haloperidol and
lorazepam. The advantage may be more rapid control
of agitation and lower neuroleptic exposure for the
patient. However, exposing the delirious patient to yet
another drug (they are often on many drugs already)
which may in itself cause confusion or agitation
makes this combination less appealing, and may com-
plicate the search for an etiology. The combination
can be useful in certain cases, such as delirium sec-
ondary to alcohol or benzodiazepine withdrawal not
adequately controlled by lorazepam alone.
For delirious patients requiring narcotics for pain,

intravenous Dilaudid® (dihydromorphone) has been
recommended.
Psychosocial interventions will not successfully treat

delirium. Certain environmental actions may be help-
ful, including the use of restraints when patients are
agitated, using a sitter, and moving the patient to a
room closer to the nurses’ station for better observa-
tion. Attention to other risk factors may impede the
development of delirium. Correcting sensory deficits
by supplying the patient with glasses or hearing aids
may be helpful. Staff can assist orientation using
clocks, night lights, or regular verbal reorientation.
Normalizing sleep by nonpharmacologic measures
such as reducing nighttime external stimuli, back
massage, calming music, and rescheduling medica-
tion regimens may help as well. A window in the
room allows for better orientation, and family mem-
bers may be able to calm the patient in some circum-
stances. However, delirium can be very frightening for
family members. Education and judgment are neces-
sary when family members are involved in the care of
a delirious patient.

5. Personality Disorders and
Medical Conditions
Personality disorders may be difficult to diagnose in Various philosophies of dealing with difficult patients
the inpatient medical setting. Patients may manifest exist, but the following are general guidelines
demanding behavior, excessive dependency or rigid- (adapted from Groves, 1997) for the psychiatric con-
ity, suspiciousness, or a host of other characteristics as sultant:
a reaction to the stress of illness, and not necessarily as
an indication of a lifelong personality pattern. Deter- 1. Safety issues are most important. Suicidal and
mining this can be time consuming, and may require a homicidal ideation must be assessed. If an immi-
more extensive history, or gathering information from nent threat exists, then patient supervision, restraint,
other informants. When personality traits do not or transfer must be considered.
directly affect ongoing medical treatment, they are
typically not a prominent focus during the usual brief 2. The consultant should resist the temptation, often
hospitalization, and referrals for outpatient follow-up proffered by the medical staff, to come in and han-
can be made when appropriate. Comorbidity with dle or take over the case in solo fashion. Rather, the
medically oriented Axis I disorders, such as factitious consultant should meet with as many staff members
or somatoform disorders, is often seen. as possible and endeavor to help them to better man-
age the case. If the staff has been divided by split-
The decision to order a psychiatric consultation, espe- ting or other factors, then providing general support
cially in inpatient settings, is at times triggered by and trying to foster better communication among
patients whom the medical staff deem obnoxious or staff members should be helpful.
disagreeable, regardless of whether they meet the for-
mal criteria for a personality disorder. Such patients 3. The staff should be assisted in providing firm and
may be demanding, frankly aggressive, non-compli- consistent limits for the patient, including limits to
ant, or excessively dependent. As Groves noted in his satisfaction of dependency needs.
review, patients of whatever diagnosis tend to prompt
psychiatric consultation whenever they are acting as if 4. The consultant should try to convey an appreciation
they have borderline personality disorder. The follow- of the stressors that the patient does face.
ing discussion centers upon behaviors often seen in
such a context. 5.The consultant should resist the trap of con-
fronting narcissistic entitlement and other rela-
So-called “difficult” patients may exhibit a marked tively primitive defenses; such confrontation
sense of entitlement and demand special treatment often is not well tolerated in the stress of the hos-
from medical staff. They may have their own ideas, pital. Instead, those working with the patient
perhaps derived from family, friends, or the media, should try to play along with entitlement, by
about what kind of treatment they ought to have. Inpa- insisting that they have at heart a desire that the
tient medical settings, with their bewildering variety patient receive the best care possible.
of caregivers who may or may not communicate well,
are conducive to “splitting” behaviors in those so pre-
disposed. Difficult patients may idealize certain staff
members and demonize others, giving rise to incon-
sistent views of the patient and subsequent bickering
and low morale among the medical staff. Some staff
members may collude with the patient’s projective
identification, that is, staff may feel and act vindic-
tively toward the patient as a result of the patient’s pro-
jection of hostility upon them (alternatively, staff
working with the same patient may unconsciously
take on a particularly nurturing and protective role in
response to different signals).
6. Personality Change Due to a 7. Psychotic Disorders
General Medical Condition
The DSM-IV diagnosis of personality change due to a Initial evaluation of the psychotic patient in the hospi-
general medical condition replaced the previous tal requires attention to the concurrent medical prob-
“organic personality disorder.” The current category lems, medication list, family history, substance abuse
includes several possible types of personality change, history, and prior psychiatric history. Many of the
such as labile, disinhibited, aggressive, apathetic, medical illnesses discussed earlier, associated with
paranoid, and “other.” A number of medical condi- psychiatric symptoms, can present with psychosis.
tions, chiefly those affecting the brain (and in particu- These include hypothryroidism, hyperthyroidism,
lar, the frontal lobes), may cause lasting changes in adrenal insufficiency, lupus cerebritis, Cushing’s syn-
personality. Some of the most common disorders are drome, hyperglycemia, hypoglycemia, porphyria, and
head trauma, cerebral tumor, stroke, Alzheimer’s infection. Additionally, many common medications
dementia, Huntington’s disease, epilepsy, and multi- can present with psychosis as part of a delirium.
ple sclerosis.
Once a medical cause is ruled out, psychiatric disor-
Personality traits often resulting from medical condi- ders that present with psychosis must be considered.
tions include disinhibition, impulsivity, and affective The chronicity of the symptoms is important in deter-
lability (most often seen with orbitofrontal lesions) as mining whether the symptoms are consistent with an
well as apathy and psychomotor retardation (often affective disorder, delusional disorder, or schizophre-
resulting from damage to the frontal convexity). Aside nia. The presence of cognitive impairment suggests
from consideration of underlying etiology, treatment that the psychotic symptoms may be attributable to a
generally is symptomatic—atypical antipsychotics, dementia. Decline in level of functioning suggests
mood stabilizers and blockers may be helpful in possible progressive dementia or schizophrenia. The
reducing impulsivity and aggression, the symptoms differential diagnosis of psychosis secondary to a psy-
that most often demand attention. Pro-dopaminergic chiatric disorder follows the diagnostic criteria out-
agents have been used for symptoms of frontal lobe lined in the Diagnostic and Statistical Manual of Men-
dysfunction. Of note, temporal lobe epilepsy long has tal Disorders. Chronic psychosis can be seen with
been associated with a personality type characterized schizophrenia, schizoaffective disorder, schizophreni-
by so-called interpersonal “viscosity,” hypergraphia, form disorder, and delusional disorder. More acute
low sexual drive, and an overconcern with religious psychoses can be seen with major depression, bipolar
and philosophical issues, but studies have failed to disorder with mania, and brief psychotic disorder.
bear this out convincingly.
The decision about which antipsychotic medication to
use for treatment of psychotic illness is directed by the
type of psychotic symptoms, the cause of the symp-
toms, and the side effect profile of the drugs. Newer
agents such as risperidone, olanzapine, quetiapine and
ziprasidone offer fewer neurologic side effects and
comparable efficacy. Clozapine is very rarely started
in an inpatient medical unit. The goal for dosage of
neuroleptic agents should be to maintain the maximal
effect at the lowest possible dose. This practice serves
to minimize side effects. High-potency typical agents
are more likely to be the cause of extrapyramidal
symptoms or an acute dystonic reaction. Both of these
problems are treated with administration of anti-
cholinergic agents such as benztropine, diphenhy-
dramine, and trihexyphenidyl. The low-potency typi-
cal agents are more likely to be the cause of excess
sedation and orthostatic hypotension. Most antipsy-
chotics can prolong the QT interval in susceptible

8. Chronic Pain
patients, particularly thioridazine in the typical class, Approach to the Patient

and ziprasidone in the atypical class. Multiple reports
implicate olanzapine as a cause of weight gain and/or Consultation-liaison psychiatrists are often called to
new onset diabetes, although other antipsychotics evaluate patients with a variety of pain complaints.
may also cause these conditions to some extent. Often, the request involves differentiating “real” pain
from pain due to a psychiatric disorder. The distinc-
Akathisia, the subjective or objective sense of restless- tion is often not realistic, since emotional factors will
ness, is another potential side effect that is seen with affect a patient’s experience of pain. Patients will at
either class of antipsychotic agent. Risk for this prob- times object to a psychiatric consultation because
lem is increased in middle-aged women. The diagno- they interpret this to mean that their physician
sis should be considered in the differential diagnosis believes their pain is “all in my head.” When these
of agitation or anxiety in a patient taking an antipsy- concerns are present, it is important for the consultant
chotic drug or an antiemetic drug, such as metoclo- to address them by explaining to the patient that a
pramide, promethazine, or prochlorperazine. psychiatry consult is generally included in a compre-
hensive approach to pain management, that pain nat-
Tardive dyskinesia is another syndrome resulting urally causes an emotional response, and that suc-
from antipsychotic therapy. This syndrome is charac- cessfully evaluating and addressing that response can
terized by abnormal involuntary movements. With lead to more effective pain relief.
typical antipsychotics, the incidence of tardive dyski-
nesia is 4% per year of cumulative antipsychotic Pain can be either acute, continuous, or chronic.
exposure, but is considerably higher in the elderly. Acute pain has been defined as resulting from a noci-
The risk is apparently less with the newer atypical ceptive stimulus (that is, a noxious stimulus, often
antipsychotics. Risk factors for development of tar- causing tissue damage). The pain may be waxing and
dive dyskinesia include advanced age, female gen- waning, and should resolve within days to 6 weeks.
der, and presence of a mood disorder. This particular (Some authorities set the duration up to 3 months.)
side effect can be relatively persistent. There has Less severe acute pain is usually responsive to milder
been some evidence suggesting that Vitamin E may analgesics such as aspirin, acetaminophen, or
reduce worsening of symptoms. NSAIDs. More severe acute pain responds to nar-
cotics. A stepwise approach to using analgesics has
Neuroleptic malignant syndrome (NMS) occurs in been recommended, beginning with aspirin,
<3% of patients treated with neuroleptic medication. acetaminophen, or the newer NSAIDs for less severe
Although it is an uncommon complication of such pain. For more severe pain, the addition of codeine or
treatment, it is potentially lethal. The syndrome is hydrocodeine is recommended. Narcotics, such as
characterized by rigidity, disorientation, elevation in morphine, are reserved for the most severe pain
creatine phosphokinase (CK), elevated white blood which will not respond to the other approaches.
cell count, diaphoresis, and hyperthermia. The syn-
drome symptoms overlap with malignant hyperther- Continuous pain results from an ongoing nociceptive
mia. The initial treatment for NMS is discontinuation stimulus such as cancer. Regular (not prn) treatment
of all neuroleptic medication. Traditional teaching has with opiates is recommended, often with pain adju-
recommended utilization of dantrolene, bromocrip- vants. Some authorities categorize continuous pain as
tine, or lorazepam to quicken syndrome resolution but a subset of chronic pain.
there is no clear evidence that medication changes the
course of the illness. The therapy for the syndrome is, Chronic pain has been defined variously as pain which
therefore, primarily supportive. Full recovery from an lasts >6 weeks or 6 months. Often, the initial nocicep-
episode of NMS must be seen before rechallenge with tive stimulus no longer exists, and central pain mecha-
an antipsychotic agent can be attempted. Of all possi- nisms are responsible for the persistence of the pain.
ble antipsychotic agents, clozapine has been shown to
have the lowest incidence of associated NMS.
Unlike patients with acute pain, patients with chronic In addition to specifically evaluating the pain, the con-
pain may accommodate to the pain and not demon- sultant should review the patient’s past medical and
strate pain behavior such as grimacing, posturing, or psychiatric record for information related to medical
restlessness. This should not be interpreted as mean- causes of pain and possible psychiatric comorbidity,
ing the patient has no pain or is malingering. and to get independent corroboration of the history
provided by the patient.
The consultant will assess the location, quality, and
duration of the pain. A limited physical examination is Types of Pain
important. Asking the patient to draw a pain diagram
can be helpful; the patient may also be asked to rate Acute, continuous, and chronic pain have been
the pain from 0 to 10, or use a visual analog scale to described.
rate the pain. The patient’s pain rating can be useful in
tracking the progress of treatment, and also for possi- Nociceptive pain results from a noxious stimulus and
bly suggesting histrionic or even manipulative fea- often causes tissue damage.
tures. (“The pain is a 15!”) Is the pain stationary or
migratory? Is it dull or sharp, burning, constant, throb- Central pain occurs in the absence of nociceptive
bing? What lessens the pain? What makes it worse? Is stimuli, and originates proximal to the usual sensory
there unusual sensitivity to nonnoxious stimuli? What pain receptors. It may have a delayed onset, be poorly
treatments have been tried, and how have they defined by the patient, and defy attempts to specifi-
affected the pain? Does the pain conform to known cally localize it; it may thus be mistaken for malinger-
physiologic parameters, such as nerve distribution? ing or factitious disorder. Opiates tend to be less effec-
Do significant life events coincide with the onset or tive for central pain. Central pain is also characterized
worsening of the pain? by unusual sensations.
Finally, how has the patient fared in dealing with the Central Pain Characteristics
pain? Not infrequently, patients will endorse a variety
of psychiatric symptoms, such as low mood, sleep dif- Allodynia refers to exquisite sensitivity to stimuli
ficulties, difficulty concentrating, and even thoughts which usually do not cause pain; for example, the
of suicide, but will attribute each of these symptoms to patient may complain of severe pain on his or her legs
the pain, adamantly denying any psychiatric disorder from the touch of the blanket, or experience pain when
such as depression. Patients who attribute a full psy- even a hair is moved in the affected area.
chiatric syndrome solely to pain may or may not be
correct, but the consultant should still do a thorough Causalgia is burning pain.
psychiatric evaluation, form a judgment about the
presence of a psychiatric disorder, and institute treat- Dysesthesias are unpleasant sensations such as tin-
ment when indicated. gling or numbness.
When there is clear evidence for significant pain, a Hyperalgesia or hyperesthesia are increased sensitiv-
review of the patient’s pain medication may reveal ity to pain or any sensation, respectively. Hypoalgesia
that doses have been too low. This may occur because or hypoesthesia are reduced sensitivity to pain or sen-
of inadequate conversion from intravenous to oral sation, respectively. Allachesthesia refers to pain
administration, or because of the treating physician’s experienced at a site distant from the initiating stimu-
concern over the potential for addiction. Studies have lus. Hyperpathia refers to pain with delayed onset and
shown that patients often suffer with more pain than is increasing severity over minutes or hours; it may
necessary. Studies also show that the risk of addiction occur with allachesthesia.
to opiates is very low in patients who have severe pain
without histories of drug abuse.

Reflex sympathetic dystrophy is a central pain syn- Depression and anxiety disorders can exacerbate pre-
drome characterized by allodynia, swelling, redness, existing pain or increase the severity of relatively
sweating, and muscle and bone wasting; it is relieved insignificant pain. The usual diagnostic criteria for
by sympathetic blockade. these disorders are applied to the pain patient,
although adapting diagnostic criteria to patients with
Examples of central pain states are diabetic neuropa- serious medical illness can be challenging. Treatment
thy, phantom limb pain, and deafferentation pain involves the usual psychopharmacologic and/or psy-
states. Central pain accounts for 20% to 50% of chotherapeutic approaches to depression and anxiety
chronic pain conditions. disorders.
Placebo Effect Somatization disorder consists of multiple pain com-

plaints in the context of multiple systems complaints.
Up to 30% to 40% of patients with medical disorders Undifferentiated somatoform disorder requires more
causing pain can experience a reduction in pain from a limited involvement of organ systems. Pain in conver-
placebo. A trial on a placebo is not an accurate or use- sion disorder must be accompanied by either motor
ful means to distinguish pain due to a primary psychi- and/or sensory deficits, and/or seizures, all with a psy-
atric disorder (eg, malingering, factitious, or somato- chogenic basis. Pain disorder is diagnosed when pain
form disorders) from nociceptive or central pain. In is the predominant symptom and psychogenic factors
addition, it may do harm to the relationship with the are judged to play an important role. Hypochondriasis
physician if the patient discovers the deception. is related to a preoccupation or fear of illness; pain by
itself is not a sign of hypochondriasis, but may coexist
Deafferentation Surgery with it. Treatment of somatoform disorders usually
involves psychotherapy, with medication use for
Surgical interventions (deafferentation procedures comorbid psychiatric conditions.
such as neurectomies, rhizotomies, tractotomies, and
cordotomies) for chronic pain patients should be Factitious disorder involves intentionally producing
avoided, if possible. They are usually not effective for or feigning a physical symptom to maintain the sick
chronic pain states, may cause additional complica- role. Malingering is intentionally producing or feign-
tions, and, in cases where some pain relief is obtained, ing a physical symptom for secondary gain, such as
relapse is common within several months. financial gain or obtaining narcotics. Treatment of
these disorders is challenging, usually cannot be
Differential Diagnosis, Associated effective within a short hospital stay, and requires
Conditions, and Treatment engaging an often-resistant patient over a longer
period of outpatient therapy.
A variety of psychiatric syndromes may be associated
with pain. These include: Psychotic patients may report pain that is bizarre or
delusional. Antipsychotics are the treatment of
1. Depression choice.
2. Anxiety disorders
3. Somatoform disorders (somatization disorder, Patients with histories of childhood trauma may be
undifferentiated somatoform disorder, overrepresented in chronic pain patient populations.
conversion disorder, pain disorder, Headaches, sexual pain, pelvic pain, and abdominal
hypochondriasis) pain are frequent complaints. Dissociative states may
4. Factitious disorders be comorbid.
5. Malingering
6. Psychosis
7. Trauma history/dissociative disorders
9. Psychopharmacology in the
Medically Ill (or Pregnant) Patient
Personality disorders, such as borderline or antisocial The use of psychotropic medications in the medi-
personality disorders, may complicate any of these cally ill can be complicated. The psychiatric consul-
psychiatric conditions. tant must determine first whether the patient is tak-
ing medications that are causing the psychiatric
Treatment of Chronic Pain symptoms. Psychosis, delirium, depression, and
anxiety can all be caused by a variety of medica-
Continuous pain patients (such as those with bone tions. When in doubt, all nonessential medications
metastases) should be afforded pain relief with nar- should be discontinued. Even when psychiatric
cotics and adjuvants. Adjuvants increase the anal- symptoms are medication-induced, treatment with
gesic effect of narcotics. Examples are stimulants psychotropic agents may still be necessary, espe-
(methylphenidate or dextroamphetamine); tricyclic cially if it is not medically possible to discontinue
antidepressants (eg, amitriptyline, imipramine, the medicine causing the symptoms.
desipramine, nortriptyline); benzodiazepines;
prostaglandin inhibitors; and antihistamines (eg, It has sometimes been said that a depressed patient
hydroxyzine). with a serious medical illness is understandably
depressed, and so treatment with an antidepressant is
Narcotics are less helpful in chronic central pain unnecessary. This notion has generally been discred-
states. Here, trials on a variety of classes of medica- ited as studies have demonstrated the value of treating
tion may be helpful, including tricyclic antidepres- comorbid psychiatric disorders in the medically ill
sants, clonazepam, carbamazepine, valproate, and even if the disorder appears psychologically reactive
gabapentin. to the primary medical illness. A clear example of this
is in poststroke depressed patients, where both medi-
Lithium has been used for the prevention of cluster cal and psychiatric outcomes are worse if the depres-
headaches. sion goes untreated.
SSRIs appear to be less effective than tricyclics in Medically ill patients with psychiatric comorbidity
reducing chronic pain. Also, potent inhibitors of the pose a challenge to the psychopharmacologist in a
P450-IID6 isoenzyme, such as fluoxetine or paroxe- variety of ways. The primary medical illness may
tine, may inhibit the breakdown of codeine into its adversely affect the way a psychotropic medication
active metabolite, thereby reducing its effectiveness in is metabolized or tolerated, and the psychotropic
controlling pain. medication may adversely affect the medical illness.
Identifying possible drug interactions poses a
Cognitive-behavior therapy may be useful in reducing major challenge.
pain behavior. In the right subject, hypnosis or teach-
ing self-hypnosis or stress management techniques Renal Disease
can be helpful in reducing pain.
Renal disease can affect the way psychotropic
agents are excreted. The two drugs in psychiatry
which rely on renal excretion are lithium and, in use
more recently, gabapentin. Gabapentin dosage
should be lowered in patients with renal insuffi-
ciency. The excretion of lithium is proportional to
renal clearance. Dangerous lithium toxicity can
occur in patients with compromised renal function,
but cautious use of lithium is still possible in
patients with elevated blood urea nitrogen (BUN)
and creatinine; dosing should “start low and go
slow.” For example a starting dose of 150 mg/day is
reasonable, with slow increments as indicated.
Patients on dialysis can take a single dose of 300 mg

of lithium after each dialysis. Geriatric patients causing increased levels of some calcium-channel
should also start low and go slow, and are at blockers, cisapride (now off the market),
increased risk for lithium toxicity even at therapeu- cyclosporine, and the antihistamines terfenadine
tic levels. Patients with dehydration can easily and astemizole (both are now off the market);
develop toxicity. NSAIDs, thiazide diuretics, and increased levels of cisapride and these antihis-
angiotensin converting enzyme inhibitors will tamines can cause potentially dangerous cardiac
increase lithium levels and can lead to toxicity. arrhythmias. Fluvoxamine can inhibit the IA2
Lithium should be avoided in patients with acute isoenzyme, and can increase levels of theophylline
renal failure. and some tricyclics.
All other psychotropics should start low and go slow, Cardiac Disease
assessing efficacy and tolerance along the way. Blood
levels may be helpful. Tricyclics and anticholinergic Tricyclic antidepressants have a variety of poten-
neuroleptics can cause urinary retention. tially dangerous cardiac effects. Because they pro-
long cardiac conduction, they are not generally safe
Liver Disease in patients with preexisting bundle-branch block or
atrioventricular (AV) block. Although they decrease
Most psychotropic drugs are metabolized by the liver. cardiac irritability and can decrease the frequency of
premature ventricular contractions, this affect has
Phase I metabolism (eg, oxidation, demethylation) been associated with increased risk in studies of
is affected in patients with liver disease, whereas postmyocardial infarction patients receiving drugs
phase II metabolism (eg, glucuronidation) is spared. with similar cardiac effects. Tricyclics also can
Thus, benzodiazepines such as diazepam and chlor- cause orthostatic hypotension; nortriptyline appears
diazepoxide can accumulate to potentially danger- to be the safest in this regard. Increased cardiac rate
ous levels, while lorazepam, oxazepam, and is common, although usually not severe. If, despite
temazepam, subject to phase II metabolism, are these cautions, the decision is made to use a tricyclic
generally better tolerated. antidepressant in a patient with cardiac disease,
ongoing consultation with the patient’s cardiologist
Psychotropics are generally protein-bound, and the is indicated.
free drug fraction exerts the therapeutic effect. Con-
sequently, patients with low protein levels may A multicenter controlled study indicates that sertra-
achieve therapeutic effects with lower doses of med- line appears to be safe in depressed patients with
ication. Psychotropics may compete for protein- unstable angina or following an acute myocardial
binding sites with warfarin, and may require a infarction. The other antidepressants have not been
reduction in warfarin dosing. studied extensively in patients with heart disease. In
small studies, paroxetine, fluoxetine, and bupropion
Rates of liver metabolism can vary among individu- appear safe and effective. Venlafaxine can increase
als. For example, tricyclic antidepressant plasma blood pressure in a dose-related fashion, which
levels can vary by a factor of 10 in patients without could be relevant in patients with preexisting heart
liver disease. However, many psychotropic agents disease or hypertension. Nefazodone and mirtazap-
can affect liver metabolism. Barbiturates, pheny- ine have not been specifically studied in patients
toin, carbamazepine, and nicotine increase the rate with heart disease. With proper precautions, ECT
of liver metabolism for a host of drugs, and may can be used safely and effectively in selected
require dosage increases in drugs such as neurolep- patients with heart disease.
tics. SSRIs, such as fluoxetine and paroxetine,
bupropion, and to a lesser extent, sertraline and Benzodiazepines and buspirone appear to be safe in
citalopram, inhibit the P450- IID6 isoenzyme, and patients with cardiac disease.
coadministration can increase levels of tricyclic
antidepressants and some lipid soluble beta blockers.
Nefazodone and fluvoxamine inhibit P450-IIIA4,
Lithium has been associated with sinus node dysfunc- ing mood stabilizers, patients contemplating preg-
tion. Phenothiazines, especially thioridazine, may nancy need to be counseled concerning the risks and
increase QRS duration and cause T-wave flattening. options, and an individualized treatment plan should
Antipsychotics have been associated with ventricular be developed. Because mania is not a benign condi-
arrhythmias in susceptible individuals, including Tor- tion for patient or fetus, the decision may be to con-
sades de Pointes. tinue mood stabilizers throughout pregnancy when
the clinical situation indicates that the risk to patient
Respiratory Disease and fetus would be too great without them. Alterna-
tively, mood stabilizers may be restarted after the first
Benzodiazepines can cause respiratory depression trimester. High-potency typical neuroleptics may be a
and should be used cautiously in patients with reasonable option in some cases. (Low-potency typi-
chronic obstructive lung disease, and may be con- cal antipsychotics appear to have a higher rate of con-
traindicated in patients with sleep apnea. Fluvoxam- genital defects.) Experience is limited with atypical
ine can increase theophylline levels and thereby antipsychotics in pregnancy. Risperidone and typical
increase anxiety. Buspirone appears to be well toler- antipsychotics are more likely to cause hyperpro-
ated in anxious patients with chronic obstructive pul- lactinemia. Pregnant bipolar patients who have dis-
monary disease (COPD). continued medication need to be followed closely.
Seizure Disorders Fetal exposure to some benzodiazepines during the

first trimester has been associated with a risk of oral
Most psychotropics can decrease the seizure thresh- cleft abnormalities in the newborn of up to 0.6%, but
old; of all antipsychotics, thioridazine and molin- these data are contradictory and there may be differ-
done appear to have the least effect, while clozapine ences among different benzodiazepines. Newborns
has the most (up to 5% at 600 mg/day). Bupropion with in utero exposure to benzodiazepines may be
can cause seizures, particularly at higher doses and subject to withdrawal symptoms, or may develop the
in some patients with bulimia. SSRIs seem to have so-called “floppy baby” syndrome, with decreased
less effect on the seizure threshold than other antide- muscle tone and autonomic instability. Some reports
pressants. Patients taking carbamazepine for seizure indicate that clonazepam in low doses appears safe for
control may need increased doses of other psy- mother and fetus, but these studies are generally small
chotropics due to carbamazepine’s effect on liver and anecdotal. Studies indicate that untreated mater-
enzyme induction. nal anxiety (and depression) during pregnancy may
lead to an increased risk of perinatal complications in
Pregnancy the newborn.
Pregnant patients with bipolar disorder pose a special Studies indicate that when antidepressants are dis-
psychopharmacologic challenge. Women with bipo- continued, there is a high rate of relapse for pregnant
lar disorder have increased risk of developing postpar- women with histories of recurrent major depression.
tum depression. Like nonpregnant patients, pregnant However, there are sparse data on antidepressants in
women with recurrent bipolar disorder have high pregnancy. Fluoxetine has had the most reports,
relapse rates when mood stabilizers are withdrawn. including prospective observations, and appears safe,
First trimester exposure to lithium has been associated although there are reports of low birth weight and
with the development of Ebstein’s anomaly (congeni- other perinatal complications, and increased risk of
tal downward displacement of the tricuspid valve). spontaneous abortion. Tricyclic antidepressants have
Recently, however, the risk of this occurrence has been used for years without major information which
been placed at 0.05%—lower than previously would clearly contraindicate their use. There is some
thought. Valproate has been associated with a 5% risk evidence that the SSRIs, citalopram, sertraline,
of neural tube defects, and carbamazepine with a 1% paroxetine, and fluvoxamine are also safe. Other
risk of spina bifida. Since relapse rates in bipolar antidepressants have less information, and none of
patients are significant within 6 months of discontinu- the studies has been controlled. When a woman with

10. Transplantation Issues
recurrent depression is doing well on an antidepres- Psychiatrists may be part of a multidisciplinary

sant, and she becomes pregnant, authorities have rec- transplant team; they may participate in regular
ommended that in general she continue on that meetings of the transplant team in addition to seeing
antidepressant. patients. Psychiatric consultation can occur during
the four stages in the process of organ transplanta-
Options for pregnant patients with depression tion: screening, pre transplant (while on the list
include continuing antidepressant treatment; switch- awaiting organ transplant), immediate post trans-
ing to fluoxetine or a tricyclic; resuming treatment at plant (postoperative), and later post transplant.
36 weeks or immediately post partum, or, cognitive Patients may be seen individually, but family
or interpersonal psychotherapy for mild to moderate involvement is often indicated.
depression. ECT has been used safely for severe
depression, particularly in emergent situations when Patients are screened to detect the presence of a psy-
delay could be catastrophic, eg, actively suicidal or chiatric condition, substance abuse disorder, or psy-
acutely manic patients. In addition to the patient’s chosocial problem which might interfere with adher-
suffering, anxiety and depression in the mother may ence to the burdensome posttransplant treatment regi-
be associated with worse fetal outcomes, making men. This might include psychiatric disorders such as
ongoing treatment throughout pregnancy a reason- depression, psychosis, substance abuse, dementia,
able option. Naturally, these options should be dis- adjustment disorders, and severe personality disor-
cussed as indicated with patients who are pregnant, ders, and psychosocial problems such as severe social
or ideally when patients are contemplating becom- isolation. Such problems can occur pre and post trans-
ing pregnant. Because of an increased volume of dis- plant. Occasionally, when there are questions con-
tribution during pregnancy and resulting lower blood cerning the altruism or competency of a living donor,
levels on stable doses, dosages of drugs may need to the consultant may be called to evaluate a donor and
be increased during pregnancy and then reduced to make recommendations about his or her suitability to
prior levels post partum. proceed. Transplant centers may refuse patients who
smoke cigarettes; in such cases, a smoking cessation
Lithium achieves a high concentration in breast milk. program is necessary.
In the past, authorities advised against this fetal expo-
sure, but more recently, use of lithium has been con- Studies to determine absolute psychiatric exclusion
sidered more acceptable when combined with moni- criteria for transplant candidates have not been con-
toring of newborn response and lithium levels. SSRIs clusive. Many programs exclude patients with active
are generally secreted in breast milk, and so far no substance abuse, dementia, active suicidal ideation,
clear problems have emerged in newborns. SSRI lev- past history of multiple suicide attempts, and severe
els can be monitored in newborns who have risk fac- mental retardation. The essential point is to identify
tors such as low birth weight or hyperbilirubinemia. problems which could seriously affect posttransplant
Data on other psychotropic agents are sparse, but it care and outcome. In this regard, a history of noncom-
has been suggested that monitoring newborn blood pliance may predict future difficulties. In any case,
levels of psychotropic drugs is indicated at 2 to 4 clinical judgment and discussions with the transplant
weeks, or if signs of toxicity develop. Research qual- team are important.
ity assays may be necessary to detect meaningful drug
levels in the newborn. Once a patient has been approved to be on the wait-
ing list for a transplant, other problems may arise.
For example, in the case of heart transplant patients,
the recipient may have a prolonged stay in the hospi-
tal while awaiting the availability of a donor heart. In
or out of the hospital, patients awaiting donor organ
availability may experience depression and anxiety
disorders, preexisting personality disorders may
blossom, or a delirium may occur. Patients with
active substance abuse are often turned down for
11. Medical Illness Presenting
With Psychiatric Symptoms
organ transplantation unless they can successfully Endocrine Disorders

achieve abstinence. In any patient with a psychiatric
or substance abuse disorder, the consultant may be Pathology affecting the thyroid gland is the classic
asked to evaluate the patient for continued suitability endocrinologic abnormality that presents with psychi-
to remain on the waiting list, and to give whatever atric symptoms. Either overactivity or underactivity of
psychiatric treatment is warranted to assist the the gland can result in psychiatric disease. Hyperthy-
patient during the often arduous waiting period. roidism can be manifested by anxiety, pressured
speech, insomnia, psychotic symptoms, impaired
Immediately after transplantation surgery, the psy- cognition, and poor concentration. Physical symp-
chiatrist may be called to evaluate and recommend toms of this illness may include enlargement of the
treatment for delirium. Delirium may result from the thyroid gland, tachycardia, fine tremor, and exoph-
direct effects of the diseased organ, anesthesia dur- thalmos. Patients will often describe palpitations, heat
ing the procedure, opiates used for postoperative intolerance, and weight loss in spite of increased
pain control, medications prescribed after the proce- appetite. Laboratory studies are remarkable for eleva-
dure, infection, or other medical-surgical complication in serum T3 and T4 with suppression of thyroid-
tions. Mental status alterations, such as delirium or stimulating hormone (TSH). Hypothyroidism can be
withdrawn depression, may be the initial presenting manifested by symptoms of depression, including
signs of postoperative infection. Once the patient has neurovegetative symptoms, as well as by cognitive
been discharged, treatment may be initiated for qual- impairment. Despite the association of hypothy-
ity of life issues, marital problems, or compliance roidism with a slowing down of the body’s functions,
difficulties. Depression may become a problem, par- in its most severe form the illness is characterized by
ticularly if the transplant is unsuccessful. Heart hypomania, delusions, and hallucinations. Physical
transplant patients appear to have a particularly high symptoms of this disease include deepening of voice,
rate of depression, as do liver transplant patients (to a dry hair and skin, delayed reflexes, and loss of the lat-
lesser extent). eral portion of the eyebrow. Patients will often
describe cold intolerance, weight gain with decrease
Posttransplant patients typically receive a multitude of in appetite, and impaired hearing. Laboratory studies
medications, necessitating a careful search for side are remarkable for an elevated TSH and a low T4.
effects or drug interactions in the presence of behavior
changes. Cyclosporine is increasingly implicated as a Hyperparathyroidism results in hypercalcemia which
cause of delirium or neurotoxicity, especially in liver can lead to personality changes, delirium, and cogni-
transplant patients; delirium or signs of neurotoxicity tive impairment. Hypoparathyroidism can result in
may occur soon after surgery, or may be delayed by hypocalcemia and hyperphosphatemia with similar
months. Patients receiving steroids, especially at neuropsychiatric symptoms as hypercalcemia. Phys-
higher doses, may experience mood disturbances, ical examination findings in this case include perioral
psychotic symptoms, or delirium. Treatment fol- tingling, Chvostek’s sign (tapping of facial nerve
lows the usual guidelines for medically ill patients. inducing facial twitch), or Trousseau’s sign (occlu-
Liver transplant patients on psychotropic medica- sion of blood supply to the proximal arm inducing
tion are more likely to develop toxicity and carpal spasm).
increased side effects. Heart transplant patients
may be vulnerable to arrhythmias when using neu- Adrenal insufficiency, or hypofunction of the adrenal
roleptics or tricyclic antidepressants. cortex, is most commonly due to atrophy of the gland.
Manifestations of this disease in the central nervous
system (CNS) are common and usually include cogni-
tive dysfunction, behavioral changes, depression, irri-
tability, and fatigue. Delirium or psychosis develop
only rarely. The physical symptoms of this disorder
include weight loss, weakness, skin pigmentation,
hypotension, hypoglycemia, and abdominal pain.
Diagnosis is confirmed by low plasma cortisol in the

face of elevated adrenocorticotropic hormone Uremic encephalopathy is found in association with
(ACTH) (primary adrenal failure), or failure of renal failure and is characterized by the classic diffi-
adrenal cortex to respond to ACTH. culties with level of consciousness, orientation, and
memory seen in delirium. Additionally, these patients
Cushing’s syndrome, or adrenal hyperfunction, is due will frequently complain of itching and a sense of
to excess endogenous cortisol. This disease is associ- something crawling on the skin.
ated with agitated depression, impaired memory, and
psychotic symptoms in a small subset of patients. Acute intermittent porphyria is a disorder of heme
Physical examination is remarkable for purple striae biosynthesis that causes excess build-up of por-
on the abdomen, hypertension, obesity, a buffalo phyrins. This is an autosomal dominant disease with
hump, and muscle weakness. Similar symptoms can onset between the ages of 20 and 50 years. Women
be seen in patients on exogenous steroids on a chronic are more often affected than men. The disease is
basis. Diagnosis is made by finding an increased 24- characterized by three discrete symptoms: acute
hour urine cortisol. colicky abdominal pain, psychosis, and motor
polyneuropathy. Additional psychiatric symptoms
Diabetes has the potential to lead to episodes of seen in association with this disease include mood
either hyper- or hypoglycemia which can present lability, depression, anxiety, and insomnia.
with neuropsychiatric symptoms. Either disordered
glucose level can lead to delirium. Hypoglycemia Wilson’s disease is the result of an error in copper
can present with confusion, tremor, agitation, or stu- metabolism that leads to liver cirrhosis and degener-
por. These symptoms can be mimicked by ingestion ation of the basal ganglia. The disease affects motor
of oral hypoglycemic agents or injection of exoge- function with varied neurologic manifestations.
nous insulin and can present in patients with and Psychiatric symptoms associated with Wilson’s dis-
without diabetes. Similarly, hyperglycemia can ease include behavior problems, psychosis, and
cause cognitive impairment, anxiety, agitation, and depression. The physical examination is remarkable
decreased level of consciousness, particularly in for Kayser-Fleischer rings which are intracorneal
patients who present with diabetic ketoacidosis. green-yellow rings of pigmentation. In the later
Diabetes itself causes increased risk for cardiovas- stages of the disease, stigmata of liver disease
cular disease and, therefore, an increased risk of including jaundice, ascites, telangiectasia, and pal-
vascular dementia over time. mar erythema may be present. Diagnosis is sup-
ported by a finding of low ceruloplasmin and ele-
Pheochromocytoma is a disease of the adrenal vated copper level, but definitive diagnosis is made
medullary tissue that results in catecholamine with liver biopsy.
release. Symptoms of panic or other anxiety disor-
ders can be associated with the hyperadrenergic state Neurologic Disorders
of the patient with a pheochromocytoma. The distin-
guishing feature of this illness is paroxysmal Epilepsy affects about 1% of the U.S. population.
episodes of severe hypertension. Diagnosis is made Of patients with epilepsy, 30% to 50% will have a
with 24-hour urine check for catecholamines and psychiatric illness during the time that they are
vanillylmandelic acid. treated for epilepsy. The term “epilepsy” applies to a
chronic disorder marked by recurrent unprovoked
Metabolic Disorders seizures. There are two main types of seizure: gen-
eralized (involving the whole brain diffusely) and
Hepatic encephalopathy is the result of hepatic failure partial (limited to a focal part of one hemisphere).
manifested clinically by altered level of conscious-
ness, memory impairment, general cognitive dysfunc- Generalized tonic-clonic seizures and absence
tion, and personality changes. Physical examination is seizures are both considered generalized types of
remarkable for asterixis. Laboratory data are usually epileptiform activity. The tonic-clonic seizure
marked by impairment in synthetic function of the (grand mal) is characterized by loss of conscious-
liver as well as elevation in the serum ammonia. ness, incontinence, tonic-clonic movement of the
limbs, and tongue biting. The postictal state is a patients who have already noted personality changes
state of delirium with the recovery period varying secondary to the abnormal brain activity. Risk factors
from minutes to hours. If the ictal event is not wit- include female gender, left-sided lesion, left handed-
nessed, then the diagnosis of postictal delirium is ness, and onset of epilepsy in puberty.
challenging, but clues to this diagnosis include
physical examination findings of blood in the mouth Multiple sclerosis (MS) is manifested by episodic
or tongue, or incontinence. neurologic symptoms attributable to multifocal white
matter inflammation, demyelination, and glial scar-
Absence seizures (petit mal) lack the dramatic motor ring. Neuropsychiatric symptoms include both cogni-
component of other seizures and are characterized pri- tive and behavioral problems. Patients with MS may
marily by alteration in consciousness during which experience a decrease in their overall intelligence over
time the patient appears to be out of touch with her time, but memory is the cognitive function that is
surroundings. This is primarily a disease that is diag- affected most often. Other cognitive deficits may be
nosed in children, with only rare instances of occur- found depending on the area of the brain that is
rence in adulthood. When this disease does develop in affected by the disease, and are often subtle enough to
adulthood, it can be manifested by rapidly appearing require formal neuropsychologic testing to elicit a
and resolving delirium or psychotic episodes. deficit. Personality changes such as increased irritabil-
ity or apathy and mood symptoms, including depres-
Partial seizures occur either with an alteration in con- sion and euphoria, are also seen in association with
sciousness (complex) or without such an alteration MS. Psychosis is a rare complication. Depression is
(simple). Complex partial seizures are also known as very common, affecting between 25% and 50% of
temporal lobe epilepsy, which is the most common patients with MS and resulting in an increase in the
type of epilepsy in adults. These seizures are charac- rate of suicide in this population. Risk factors for sui-
terized by automatisms such as lip smacking, repeated cide in MS patients include onset of MS before the
swallowing, or another complex motor activity that is age of 30 years, recent diagnosis, and male gender.
not goal directed and is inappropriate. Simple partial
seizures can be manifested by a multitude of diverse Brain tumors can present with a variety of psychi-
symptoms from unilateral sensory disturbances to atric symptoms depending on the type and location.
complex emotional phenomenon. The aura, which Eighty percent of brain tumor patients who experi-
refers to the subjective part of the seizure, can include ence psychiatric symptoms will have a tumor located
autonomic sensations such as blushing, hyperventila- in either the frontal or limbic regions. The history
tion, and fullness in the stomach. The cognitive sensa- and neurological examination are essential to diag-
tions such as déjà vu, jamais vu, olfactory hallucina- nose these tumors. Similarly, cerebrovascular dis-
tions, and derealization, as well as affective sensations ease can present with a multitude of symptoms.
such as fear, panic, and depression, are often confused Bilateral strokes can cause a pseudobulbar palsy
with psychiatric disease. marked by dysarthria, dysphagia, and emotional
lability. The emotional response in these patients is
In-between seizures, in the interictal period, many often considered inappropriate to the situation.
epileptic patients complain of psychiatric symptoms. Pathologic laughing or crying may occur.
Personality disorders are the most frequent diagnosis
reported in these patients, particularly those with Huntington’s disease is a progressive hereditary disor-
epileptiform activity emanating from the temporal or der that presents in adulthood. The hallmarks of the
frontal lobes. Psychotic symptoms are also relatively disease are movement disorder, dementia, and person-
common, with 10% to 30% of all complex partial ality disorder. Symptoms usually appear between the
epilepsy patients complaining of psychotic symp- ages of 35 and 40 years. The three characteristic mani-
toms at one time or other. Most often, these psychotic festations of the disease may present together or sepa-
symptoms manifest themselves as hallucinations or rately with onset of each separated by years. The onset
paranoid delusions in addition to problems with cir- of symptoms is insidious. Early psychiatric symptoms
cumstantiality. The onset of psychotic symptoms is may include irritability, inattention to activities of daily
variable, but often presents itself in longtime epilepsy living, poor impulse control, and depression. Over

time, there is progression to loss of intellectual capac- Nutritional Disorders
ity with impairment of memory, violent outbursts,
occasionally psychosis, and ultimately frank dementia. Niacin deficiency, also known as pellagra, is associ-
ated with a host of neuropsychiatric symptoms includ-
Infectious Disorders ing apathy, irritability, sleep disturbances, depression,
and delirium. Physical symptoms include peripheral
Neurosyphilis is a late complication of infection with neuropathies, diarrhea, and dermatitis. The psychi-
Treponema pallidum, usually occurring 10 to 15 years atric and medical symptoms in combination make up
after initial infection. The frontal lobes are most com- the 5 Ds that historically define pellagra: diarrhea,
monly affected with the result being apathy, poor judg- dementia, dermatitis, delirium, and death. The illness
ment, and irritability. About 10% to 20% of patients will occurs in alcoholics, vegetarians, and in those with
experience delusions of grandeur. Currently, the popula- disadvantaged socioeconomic status.
tion of people with AIDS is most at risk for development
of this disease. Physical examination is remarkable for Thiamine deficiency can cause a variety of clinical
the Argyll-Robertson pupil, tremor, hyperreflexia, and syndromes. Wet beriberi is characterized by conges-
dysarthria. Diagnosis is made with lumbar puncture tive heart failure as the primary problem whereas
showing elevated protein, lymphocytosis, and positive dry beriberi is characterized by peripheral neuropa-
Venereal Disease Research Laboratories test. thy. Wernicke syndrome consists of abnormal eye
movements, gait disturbance, and dementia. In the
Herpes simplex encephalitis commonly affects the tem- acute state, Wernicke syndrome is characterized by
poral and frontal lobes. Neuropsychiatric symptoms a state of global confusion with apathy, impaired
include olfactory or gustatory hallucinations, personal- memory, lethargy, and disorientation. Korsakoff
ity changes, bizarre purposeless behavior, and altered syndrome consists only of psychiatric symptoms
level of consciousness. Psychotic symptoms are also and usually becomes evident once the psychiatric
possible. Cerebrospinal fluid (CSF) will show pleocy- symptoms of Wernicke syndrome respond to treat-
tosis with predominance of lymphocytes. EEG may ment. With Korsakoff syndrome, there are antero-
show characteristic temporal lobe spikes. MRI will grade and retrograde amnesia. Confabulation can
often show increased T2 intensity in the temporal or occur with Korsakoff syndrome, but if initially pre-
frontal lobe regions. Diagnosis is made definitively by sent tends to resolve.
polymerase chain reaction amplification of herpes sim-
plex virus (HSV) DNA in the CSF. Cobalamin (B12) deficiency usually develops
because of impaired ability on the part of the gastric
With the advent of human immunodeficiency virus mucosal cells to secrete intrinsic factor. The intrin-
(HIV) infection and AIDS, the list of infectious ill- sic factor is necessary for the normal absorption of
nesses that can present with psychiatric symptoms B12 in the ileum. Psychiatric symptoms such as
has grown. depression, irritability, and apathy are common.
Megaloblastic madness is the term used to describe
Autoimmune Disorders delirium, delusions, and hallucinations attributed to
B12 deficiency. Physical examination may show a
Systemic lupus erythematosus is the autoimmune dis- peripheral neuropathy. Laboratory studies may
ease that most commonly presents with psychiatric show a megaloblastic anemia, but neuropsychiatric
symptoms. These symptoms include depression, symptoms may precede the development of hemato-
emotional lability, confusion, and anxiety. Delirium logic abnormalities.
may be present with cerebritis. Treatment of active
disease with steroids may precipitate psychotic symp- Relatively common life-threatening medical con-
toms or mania. It is often difficult to distinguish ditions can present with psychiatric symptoms.
between cerebritis and steroid psychosis. The natural These include myocardial infarction, pulmonary
history of lupus is that 50% of patients will eventually embolus, subarachnoid hemorrhage, meningitis,
show evidence of neuropsychiatric illness at some malignant hypertension, endocarditis, and intoxi-
time in the course of their disease. cation syndromes.
12. Neuropsychiatric
Manifestations of HIV
HIV-1 is the RNA virus that causes the majority of are not complete. One recommended treatment course
HIV-related illnesses in the world. HIV is present in is initiation of triple drug combination therapy with
bodily secretions including blood, cervical and vagi- two nucleoside reverse transcriptase inhibitors and
nal secretions, semen, tears, saliva, CSF, and breast one protease inhibitor. Recommendations for initial
milk in infected persons. Transmission occurs through treatment should be individualized.
transfer of infected blood (eg, through use of shared
needles) or through sexual intercourse. Blood used for The differential diagnosis of psychiatric symptoms in
transfusion and organs for transplantation are tested the patient with HIV must include consideration of
for HIV and generally are no longer a mode of infec- diagnoses that occur commonly in the general popula-
tion. Children may be infected in utero or in the pro- tion. Substance-related disorders occur with high fre-
cess of breast feeding with infected milk. quency in the HIV population and can complicate the
diagnosis of cognitive impairment, affective disor-
Following infection with HIV, there is often a subclin- ders, or delirium.
ical viral syndrome that occurs in the acute phase of
infection, approximately 3 to 6 weeks after exposure. Determination of the degree to which HIV is affect-
Rarely, acute infection will present with a flu-like syn- ing a patient’s neuropsychiatric condition is depen-
drome including headache, fatigue, rash, thrombocy- dent on the stage of the patient’s HIV disease. Median
topenia, and elevated sedimentation rate. duration of asymptomatic stages is 10 years. CD4
counts of >200 lessen the chance that a problem is
Thereafter, the virus targets the CD4+ lymphocyte related to opportunistic infection and counts of >500
population by binding via a glycoprotein on its surface make this virtually impossible. Similarly CD4 counts
to the CD4 receptor on T4 lymphocytes. Once bound of >500 make the possibility of HIV-associated
to the lymphocyte, the virus replicates, thereby injur- dementia more unlikely. Side effects from the numer-
ing and killing the host cell in the process. The result is ous medications that many of these patients are pre-
impaired cell-mediated immunity with eventual scribed need to be taken into account. In the evalua-
severe immunosuppression, allowing for develop- tion of patients with symptoms of delirium, mania,
ment of infection and neoplasms. There is growing anxiety or depression in the context of symptomatic
evidence for the notion that HIV-1 quickly and HIV disease or significant immunocompromise,
directly infects the brain targeting astrocytes and HIV-related conditions should be high on the differ-
microglia. Direct infection of glial cells by the virus ential list. Diagnostic work-up in such cases may
induces a cell-mediated immune response that results need to include neuroimaging, EEG, lumbar punc-
in demyelination, astrocytosis, cortical atrophy, and ture, chest radiograph, arterial blood gas, serologic
compromise of the blood-brain barrier. There is also testing for endocrinopathies, blood count, elec-
some evidence that HIV causes direct neuronal injury trolytes with BUN and creatinine, vitamin levels,
and death by an unknown mechanism. Location of RPR and ammonia levels. Mental status changes in
HIV-related brain injury is primarily subcortical with the patient with symptomatic HIV disease have a
some impact on the limbic system. Because of this broad differential which includes the following:
direct action of the virus on the brain, HIV neurocog-
nitive impairment can occur on people who do not yet 1. CNS infection including cryptococcus, histo-
meet the criteria for AIDS. plasma, toxoplasma, progressive multifocal
leukoencephalopathy, cytomegalovirus; HSV,
In the scope of treatment for HIV, there are many new mycobacterium avium-intracellulare, tuberculosis,
drugs available that can lengthen the time course of and treponema pallidum
development of severe immunosuppression and mor-
bidity/mortality related to HIV. Currently, treatment is 2. Tumors including primary or secondary CNS
recommended for patients with a viral load >5000 to lymphoma, Burkitt’s lymphoma, and Kaposi’s
10,000 copies/mL irrespective of the CD4 count and sarcoma of the CNS
for patients with a low HIV RNA level but low CD4
count of <500, although data supporting these criteria

3. Adrenal insufficiency secondary to infection of the of these patients will also have overt neurologic
adrenal cortex abnormalities such as ataxia, prominent tremor, exag-
gerated deep tendon reflexes, motor weakness, and
4. Vitamin deficiencies incontinence. Risk factors for development of HAD
are older age, injected drug use, decreased body
5. Anemia mass, constitutional symptoms, loss of blood-brain
barrier integrity, and development of antiretroviral
6. Metabolic disturbances including hypoxia, renal drug resistance.
insufficiency or failure, hypo- or hypercalcemia,
dehydration, hyper- or hyponatremia, hyperam- The diagnosis of HAD remains one of exclusion, yet it
monemia is considered an AIDS-defining illness. Once all other
possible causes for neuropsychiatric symptoms have
6. Substance intoxication or overdose been eliminated, then the focus can be shifted to
treatment for HAD. Antiretroviral therapy is the
7. Trauma mainstay of treatment geared toward slowing the
progression of disease. Symptomatic treatment with
8. Medication side effect psychotropic medications can be initiated as war-
ranted but with attention to the fact that patients with
(Adapted from Table 22-1. Massachusetts General HAD are more sensitive to medication and require
Hospital Handbook of General Psychiatry.) lower doses than the general population.
Methylphenidate or dextroamphetamine may be
The primary neurocognitive complications of HIV helpful in improving concentration, attention, apa-
can be broken down into two categories: HIV-associ- thy, depressed mood, and slowed cognition.
ated mild neurocognitive disorder (HIV-MND); and
HIV-associated dementia (HAD). These two cate- Patients with HIV are at increased risk for suicide.
gories can be considered two separate points on a con- Risk factors for suicide in HIV patients include white
tinuum where the major difference is the extent to race, younger age, substance abuse or dependence,
which the cognitive impairment affects the patient’s personality disorder, major depression, and past his-
daily functioning. tory of suicide attempt.
HIV-MND and HAD are forms of subcortical disease.

In the early stages of HIV infection when HIV-MND
may be diagnosed, neuropsychiatric manifestations
are minimal. Neuropsychological testing in these
stages demonstrates cognitive impairment marked by
difficulty with information processing speed and ver-
bal memory. Early symptoms reported by patients
include apathy, lethargy, and social withdrawal that
can look like major depression. Additionally, forget-
fulness, poor concentration, slowed information pro-
cessing, difficulty with shifting sets, and difficulty
with coordination of tasks are sometimes noted. In the
later stages of HIV infection, neuropsychiatric impair-
ment becomes more obvious. At the time of diagnosis
with AIDS, about 50% of patients have a neuropsy-
chological deficit. Up to 30% of patients will develop
dementia at some point in the late stages of HIV. At
such time, symptoms include severe verbal memory
loss, psychotic features, irritability, and mania. Most
Table 4
Antiretroviral Medications
Nucleoside Reverse
Transcriptase Inhibitors Trade Name Side Effects
Zidovudine Retrovir Fatigue, nausea, headache,

insomnia, mania, depression,
irritability
Lamivudine Epivir Insomnia, malaise, headache,

neuropathy, nausea, anorexia
Didanosine Videx, ddI Insomnia, mania, peripheral

neuropathy
Stavudine Zerit, d4T Mania, peripheral neuropathy,

pancreatitis
Abacavir Ziagen Insomnia, headache, anorexia
Protease Inhibitors
Indinavir Crixivan Kidney stones
Saquinavir Invirase Asthenia, hyperglycemia, nausea
Ritonavir Norvir Perioral numbness, asthenia
Nelfinavir Viracept Fatigue, headache, decreased

concentration
Amprenavir Agenerase Depression, mood disorders
Non-Nucleoside Reverse Transcriptase Inhibitors
Nevirapine Viramune Fatigue, headache, irritability,

confusion and elevation in GGT
Effaverinz Sustiva Vivid dreams, mental status changes
Delaviradine Rescriptor Fatigue, anxiety, depression

13. Drug Intoxication and
Overdose
Pertinent history in the case of a patient with potential Tricyclic antidepressant overdose can present with
overdose includes an evaluation of current medica- hypotension, arrhythmias, seizures, hyperthermia,
tions, medications in the home that may belong to and coma. Specific cardiac effects include conduction
someone else, over-the-counter medications, herbal or delays manifest as QRS prolongation, sinus tachycar-
diet remedies, illicit drug use, events of the day pre- dia, and torsades de pointe. Seizure and decreased
ceding mental status changes including possible toxic level of consciousness are the most common CNS
exposures, and recent changes in psychosocial situa- effects. Treatment is directed at monitoring the electro-
tion that may have precipitated a suicide attempt. cardiogram, alkalinization of urine, and protection of
the airway.
Overdose with certain classes of medication results in
toxic symptom complexes. Sympathomimetic medi- Serotonin syndrome can result from overdose of sero-
cations including cocaine, amphetamine, over-the- tonin reuptake inhibitors or from combination drug
counter decongestants, caffeine and theophylline pre- effect. The symptoms of serotonin syndrome include
sent with tachycardia, hypertension, hyperreflexia, mental status changes, agitation, myoclonus, hyper-
delusions, paranoia, and diaphoresis. reflexia, diaphoresis, tremor, diarrhea, fever, and inco-
ordination. Treatment is supportive and benzodi-
Opiate medications including a wide array of com- azepines can be helpful.
monly used pain medications present with hypoten-
sion, respiratory depression, bradycardia, hypother- Lithium overdose is marked by tremor, dysarthria, and
mia, decreased level of consciousness, miosis, and ataxia in the early stages. These symptoms progress to
diminished bowel sounds. impaired consciousness, myoclonus, seizures, and
coma. The longer the patient has been exposed to high
Cholinergic medications including pesticides present lithium doses, the worse the prognosis for recovery
with confusion, restlessness, tremors, delirium, excess from toxic effects. Lithium toxicity is a medical emer-
salivation and lacrimation, and seizures. gency because it can result in permanent neurologic
damage. The treatment of choice for the severely toxic
Alcohol intoxication is a common presentation in psy- patient is hemodialysis.
chiatry. Ethanol levels vary greatly among individuals
as does the effect of certain blood alcohol levels. In an Benzodiazepine overdose is manifested by disinhibi-
individual who has no tolerance to ethanol, a blood tion, slurred speech, impaired memory, respiratory
alcohol level just >250 mg% can result in respiratory depression, stupor, and eventually coma. The treat-
depression, coma, and stupor. Levels of alcohol >400 ment is supportive. Flumazenil is a benzodiazepine
mg% are uniformly associated with respiratory receptor antagonist that has a short half-life but can be
depression, loss of protective reflexes, hypothermia, helpful as a diagnostic tool.
and death.
Barbiturate overdose results in incoordination, psy-
Cocaine intoxication presents as a sympathomimetic chomotor retardation, impaired memory, respiratory
syndrome. Treatment is supportive with attention to depression, nystagmus, hypotonia, and diminished
the possibility of seizure, cardiac arrhythmias, or an reflexes. Treatment is supportive.
acute coronary syndrome.
Illicit drug intoxication has a variety of different pre-
sentations, including physiologic and psychiatric
effects, depending on the drug ingested.
14. Somatoform Disorders
Table 5
In DSM-IV, the somatoform disorders comprise som-
The Physiologic and Psychiatric Effects of atization disorder, undifferentiated somatoform disor-
Intoxication with Various Substances der, conversion disorder, pain disorder, hypochondria-
sis, body dysmorphic disorder, and somatoform disor-
der not otherwise specified. The distinguishing hall-
Cocaine marks of these disorders are somatic complaints that
imply medical illnesses, but which cannot be linked to
Pupillary dilation, blood pressure increase or demonstrable organic pathology; in addition, psycho-
decrease, heart rate increase or decrease, diaphore- logical factors play a significant role in provoking and
sis, chills, nausea, vomiting, muscular weakness, sustaining the disorder in question.
confusion, anorexia, insomnia, hyperactivity, rapid
speech, adrenergic hyperactivity, chest pain, The physical symptoms of somatoform disorders are
seizures, dyskinesia unintentional and unconscious, as opposed to those of
factitious disorder and malingering, in which symp-
Amphetamine toms are voluntary to some extent. However, some
have viewed all such disorders as constituting a con-
Similar symptoms to cocaine intoxication; also para- tinuum, ranging from less to more conscious adoption
noid psychosis without evidence of disorientation of “the sick role.” Those disorders under psychologi-
cal factors affecting medical condition (often
Barbiturates
described as “psychosomatic” disorders) differ from
somatoform disorders in that the former are associ-
Incoordination, psychomotor retardation, poor mem-
ated with a diagnosed medical condition. Because
ory, disinhibition, emotional lability, poor judgment,
patients with somatoform disorders tend to be preoc-
respiratory depression, nystagmus, hypotonia, dimin-
cupied with physical symptoms, they are often seen in
ished reflexes
the offices of primary care and other nonpsychiatrist
healthcare providers.
PCP
Vertical or horizontal nystagmus, psychosis with

behavioral disturbance, seizures, muscle rigidity,
ataxia, diminished pain response, hyperacusis,
hypertension or tachycardia, coma
Cannabis
Conjunctival injection, increased appetite, dry mouth,

tachycardia, impaired motor coordination, impaired
judgment, euphoria
Hallucinogen
Perceptual disturbances occurring in the waking

state, pupillary dilation, tachycardia, diaphoresis,
blurring of vision, tremors, incoordination
Inhalant
Dizziness, euphoria, blurred vision, diminished

reflexes, unsteady gait, slurred speech, incoordina-
tion, tremor, nystagmus

15. Somatization Disorder
Definition Clinical Features
Somatization disorder is marked by multiple physical Patients with somatization disorder tend to view
complaints, beginning before the age of 30 years and themselves as severely ill and suffer considerable dis-
occurring over a period of years, which cannot be ability. Common symptoms in the United States (clin-
fully accounted for by a medical condition or direct ical presentation may differ among cultures) are pain
effects of a substance. The DSM-IV diagnostic crite- in the head, abdomen, back, and joints; nausea and
ria require four different pain symptoms, two gas- diarrhea; sexual indifference, erectile dysfunction,
trointestinal symptoms other than pain, one sexual and irregular menses; and conversion symptoms such
symptom other than pain, and one pseudoneurologic as paralysis, numbness, seizures, or even dissociative
symptom. Making the diagnosis does not require that symptoms such as amnesia. Patients often engage in
all of the above symptoms begin before the age of 30 doctor-shopping in an effort to find explanations for
years (in fact, only at least one of them must do so), their distress.
nor must all of them exist simultaneously.
The majority of patients with the disorder have a life-
Epidemiology time history of comorbid mood disorder, and anxiety
and personality disorders are common as well.
Estimates of lifetime prevalence rates have varied
widely, averaging 1% among women and 0.1% in Prognosis
men. The disorder occurs in both genders, but is
estimated to afflict women between 5 and 20 times By definition, somatization disorder begins by the age
more often than men; the gender ratio is believed to of 30 years. It tends to be a chronic but fluctuating ill-
vary between cultures according to the prevailing ness, with symptom emergence often correlating with
idioms of somatic distress (for instance, the preva- emotional distress. Patients often describe themselves
lence in men is higher in Latin American and as even more ill than do those with chronic medical
Mediterranean countries). conditions; therefore, their lives are often disrupted,
and they are rarely able to work. No clearly effective
Etiology treatment has been found.
The cause of somatization disorder is unknown, Treatment

although numerous theories exist. The disorder has
been considered a kind of social and emotional com- Management is the rule in somatization disorder, as
munication, that is, an unconscious manipulation of no definitive treatment is known. Few empirical
the environment. The concept of alexithymia has been studies have been done, but the following manage-
advanced by Nemiah and Sifneos as an inability to ment strategies have been correlated with improved
introspectively identify and verbally express emotion, functioning in patients with the disorder: identifica-
which leads to expression through physical symp- tion of the primary care physician as the patient’s
toms. Psychoanalytic theorists have often explained main physician; establishment of regular visits about
somatic syndromes as substitutions for repressed once a month; and referral to mental health care
instinctual impulses. where possible. A caveat is that even patients with
somatization disorder do have medical illnesses, so
Neuropsychological testing has demonstrated non- complaints should never be dismissed, but diagnos-
dominant hemispheric dysfunction in patients with tic tests and procedures should only be done when
somatization disorder. There is also significant evi- clearly indicated.
dence for genetic associations—male relatives of
women with somatization disorder have an increased
risk of antisocial personality disorder and substance-
related disorders.
16. Undifferentiated Somatoform
Disorder
Definition Prognosis
Undifferentiated somatoform disorder is character- The course of the disorder is variable, depending on
ized by one or more physical complaints that last for at the number and severity of symptoms and the disabil-
least 6 months and that cannot be fully accounted for ity produced by the symptoms.
by a medical condition or effects of a substance. The
diagnosis excludes symptoms better explained by
another mental disorder (eg, mood disorder or anxiety Treatment
disorder, which often has somatic manifestations).
Recommended management of undifferentiated
The disorder was introduced in DSM-III-R after it had somatoform disorder is similar to that of somatiza-
become clear that large numbers of patients, particu- tion disorder.
larly in primary care settings, had somatoform presen-
tations but did not meet the stringent criteria of soma-
tization disorder.
Epidemiology
The disorder’s relatively recent adoption and loose

definition have limited empirical studies of preva-
lence, but it is widely held to be much more common
than somatization disorder. Estimated prevalences of
5% to 10% have been quoted. As with other somato-
form disorders, women constitute the great majority
of patients. Undifferentiated somatoform disorder
has been shown in some studies to occur more fre-
quently in patients who are older and of lower socioe-
conomic status.
Etiology
Theories about the causes of undifferentiated somato-

form disorder are very similar to those associated with
somatization disorder.
Clinical Features
Complaints most often seen with this disorder are

fatigue, loss of appetite, and gastrointestinal distress.
“Neurasthenia,” a syndrome of fatigue and weakness
that is included in ICD-10 and widely diagnosed in
many parts of the world outside of the United States, is
classified in DSM-IV as undifferentiated somatoform
disorder if symptoms have lasted at least 6 months.
Patients with the latter disorder have a significantly
higher rate of comorbid psychiatric conditions than
does the general population.

17. Conversion Disorder
Definition ronment. Psychoanalytic theorists have maintained

that conversion represents the transformation of the
Conversion disorder consists of one or more symp- anxiety of unconscious intrapsychic conflict into
toms affecting voluntary motor or sensory function somatic symptom (ie, a symptom is a symbolic
that cannot be fully accounted for by a general med- compromise that allows partial expression of a
ical condition or effect of a substance. Included in primitive impulse and that allows for blissful
the DSM-IV criteria is the clinical judgment that unawareness of the unconscious wish and unaccept-
“psychological factors” are held to be associated able desire). The resulting relief from anxiety is
with the symptom because of the correlation with considered to be primary gain, in contrast to sec-
“conflicts and other stressors”—as such, it is one of ondary gain, which refers to gains from the environ-
the few DSM diagnoses that includes an inference ment, which may include attention and care from
of etiology. The diagnosis may be specified as others, avoidance of responsibilities, or even finan-
marked by motor symptoms, sensory symptoms, cial rewards.
seizures, or a mixed presentation.
Patients with conversion disorder have been shown
Concepts inherent in conversion disorder have to have a number of neuropsychological impair-
existed since ancient times under the guise of hys- ments, including decreased attention and short-term
teria, but the term “conversion” was first used by memory, as well as imbalance of interhemispheric
Sigmund Freud and Josef Breuer in reference to processing. The fact that most such patients are
Anna O., whose somatic symptom was held by women, and that unilateral symptoms most com-
them to be a substitution for a repressed thought. monly occur on the left side, has suggested to many
The disorder was named “conversion reaction” in that nondominant right hemispheric dysfunction
DSM-I. Only in DSM-IV was the etiologic suppo- may be involved.
sition of unconscious mechanisms replaced by the
more general notion of “psychological factors.” The Clinical Features
boundaries of the diagnosis are vague, for when it
occurs in the context of somatization disorder, con- Common symptoms of conversion disorder are
version is a symptom and not a separate disorder. In seizures (or as they commonly are known, “pseudo-
addition, it has been argued that apparent alterations seizures”), paralysis, weakness, aphonia, abnormal
of consciousness, such as those that sometimes gait, and involuntary movements. In all cases, a
occur during “pseudoseizures,” should be classified thorough medical and neurologic evaluation is nec-
as forms of dissociation. essary, as numerous organic disorders, including
MS, brain tumor, hyperthyroidism, and systemic
Epidemiology lupus erythematosus, have been misdiagnosed in the
past as conversion disorder.
Conversion disorder is rare; most surveys in general
samples have suggested prevalence rates of <1%. The Typically, conversion symptoms do not correlate
female/male ratio is at least 2:1, and the disorder is with established anatomy and physiology. Sensory
thought to occur more commonly in rural areas and symptoms often do not correspond to known nerve
among those of lower socioeconomic classes. It has distributions. Alleged weakness may vary with
been argued that the incidence of the disorder may be effort and between examinations. It is often difficult
declining, and may be significantly lower than during to distinguish clinically between actual seizures and
the 19th and early 20th centuries. pseudoseizures. Patients usually do not suffer injury
or incontinence during pseudoseizures, although
Etiology such is possible. Occurrence of pronounced motor
convulsions in the context of no characteristic
Theories of causation of conversion disorder are abnormalities on EEG monitoring is highly sugges-
similar to those hypothesized for somatization dis- tive of conversion disorder. Also, as many as a third
order. Conversion disorder may be a means of of pseudoseizure patients have actual epilepsy as
unconscious control and manipulation of the envi- well. Thus, questioning patients or their families
18. Pain Disorder
about the occurrence of “two different kinds of Definition

seizures” may be helpful in determining the coexis-
tence of true seizures and pseudoseizures. Pain disorder is diagnosed when pain dominates the
clinical presentation and is not fully accounted for by
“La belle indifférence,” an unexpected unconcern a medical condition. The subjectivity of pain and its
about disability, traditionally has been associated with variability between individuals are such that it is often
conversion disorder, but it is often absent; dramatic difficult to decide how much pain any given organic
and histrionic presentations are common as well. lesion should give rise to. As is the case with conver-
Finally, no one finding is pathognomonic of the diag- sion disorder, the diagnosis of pain disorder entails a
nosis, which can only be made in the context of a thor- clinical judgment that psychological factors are sig-
ough medical evaluation and considerable exploration nificantly associated with the symptoms. Pain disor-
of psychosocial antecedents; even then, it often der should be accompanied by one of three specifiers,
remains provisional. depending on whether it is associated chiefly with
psychological factors, with both psychological factors
Prognosis and a general medical condition, or chiefly with a gen-
eral medical condition.
Conversion disorder most commonly occurs from late
childhood to adulthood; while it may occur in older Epidemiology
adults, the presence of a medical condition should be
more strongly considered in such cases. Some studies The variability of presentation of pain disorder hin-
have shown that as many as 25% of patients diagnosed ders precise estimates of prevalence, but the disor-
with conversion disorder are later found to have a der is held to be common, with at least 10% of
medical condition explaining their symptoms. adults having some disability from back pain alone.
Peak incidence occurs in the fourth and fifth
Conversion symptoms tend to improve sponta- decades of life, and the disorder is more prevalent in
neously, especially in the context of a supportive individuals of lower socioeconomic class. Studies
environment in which it is suggested that they will indicate that approximately twice as many women
get better. However, recurrence of symptoms is com- as men suffer from pain disorder.
mon. Acute onset, clearly associated stressors, and
above average intelligence are markers of better out- Etiology
come. Pseudoseizures are associated with worse out-
come than are symptoms of paralysis or isolated sen- Description of the multifarious neurologic sources of
sory complaints. pain is beyond the scope of this discussion. It has long
been known that the experience of pain is highly field
Treatment or state dependent; for example, wartime wounds
often are well tolerated in the intensity of battle, but
As with other somatoform disorders, conversion dis- become excruciating once the excitement has abated.
order has no definitive treatment. It is widely held that Depression, anxiety, and general stress are known to
successful management stems from a strong and car- make pain worse. In other words, the CNS signifi-
ing therapeutic relationship, one that provides a cantly modifies pain threshold and experience. The
secure setting allowing symptoms to decrease. Point- gate control theory of pain posits that as peripheral
ing out to patients that symptoms are manifestations pain signals arrive in the dorsal horn of the spinal cord,
of psychological problems tends not to be helpful, they are modified by descending signals from the
although some will accept the notion that “stress” is brain. Endorphins, serotonin, and substance P are
somehow involved. Developing better skills of verbal thought to be principal actors in the process.
communication may obviate the need for somatic
symptoms. On some occasions, benzodiazepines As with all somatic symptoms, pain may be viewed as
may be helpful in reducing the underlying anxiety of having interpersonal explanations—individuals may
conversion disorder. unconsciously learn that pain seems the most effective
way of eliciting care from the environment.

19. Hypochondriasis
Clinical Features Definition
By definition, pain dominates the clinical presenta- Hypochondriasis is a preoccupation with or fear of
tion of pain disorder, and other symptoms—insom- having a serious disease based on one’s misinterpreta-
nia, anorexia, nausea, or any of a host of com- tions of physical symptoms. By definition, the con-
plaints—are secondary. Pain may occur anywhere cern persists despite appropriate medical investigation
in the body, but the most common sites are the head, and reassurance; yet, the belief is not of delusional
lower back, and pelvis. Most clinicians are familiar extent. The worry lasts at least 6 months and is not a
with what has come to be known as pain behavior, component of another mental disorder. The DSM-IV
which entails dependency, passivity, catastrophiz- diagnosis allows for a specifier of “with poor insight.”
ing, avoidance of activity, and helplessness, or in
other words, pain as a way of life. The notion of hypochondriasis has existed since
ancient times; its name is derived from “hypochon-
It is important to note that chronic pain is not associ- drium,” a previous term for the area beneath the rib
ated with grimaces, obvious agony, or the vital sign cage, that is, the abdomen, from whence complaints
changes that one would expect with acute pain. The often originated. The disorder appeared in DSM-I,
above are merely guidelines; ultimately, the subjectiv- and its diagnostic criteria have undergone only minor
ity of pain must be respected, unless frank malinger- changes since then.
ing is suspected. A common misperception is that an
analgesic response to a placebo demonstrates “psy- Epidemiology
chogenic” pain; it does not, as a significant number of
individuals with cancer and other kinds of intractable The overall prevalence of hypochondriasis is not
organic pain will also have some response to placebo. known, but it is estimated to exist in between 5% and
10% of patients in general medical practices. Onset
Prognosis may occur at any time, but is most common in early
adulthood. In contrast to most somatoform disor-
The course varies widely, depending on the source ders, hypochondriasis is equally common in males
and intensity of pain. Unresolved and pending litiga- and females.
tion is associated with a worse prognosis.
Etiology
Treatment
One explanation for hypochondriasis is the misattri-
Somatic treatments of pain are detailed elsewhere in bution of pathologic meanings to normal bodily sen-
this volume. As with other somatoform disorders, a sations (although it is unclear why such would
respectful and caring therapeutic relationship, cou- occur). According to some psychodynamic theories,
pled with diagnosis and treatment of comorbid medi- hypochondriasis results when anger is alternatively
cal and psychiatric conditions, is important. Treat- displaced onto the self and expressed as help-reject-
ment should be multidisciplinary, and may include ing complaining. Behavioral theorists have held that
visual imagery, relaxation (muscle tension has been the disorder is a learned means to attainment of the
shown to exacerbate pain), hypnosis, and physical sick role and its associated benefits. Finally, some
therapy. Cognitive-behavioral psychotherapy—usu- have speculated that hypochondriasis may represent
ally of the group variety—for chronic pain focuses not a variant of anxiety disorder or of obsessive-compul-
upon getting rid of the pain entirely, but upon coping sive personality disorder.
skills and maintaining activity and productivity.
20. Body Dysmorphic Disorder
Clinical Features Definition
Patients with hypochondriasis most commonly are Body dysmorphic disorder (BDD) is characterized by
preoccupied with a grave disease that threatens their a disabling preoccupation with a physical anomaly
ability to function. As with other somatoform disor- that either is wholly imagined or is too minor to war-
ders, requests and demands for numerous diagnostic rant such concern. Facial features are most commonly
tests, as well as doctor shopping, are common. A involved, but afflicted individuals may agonize over
diagnosis of hypochondriasis requires that one rule any body part, including the abdomen, buttocks,
out other somatoform disorders, factitious disorders, breasts, and genitals. Reports of such cases have
as well as the somatic variant of delusional disorder, existed since the 19th century, but the disorder only
although at times it may be difficult to ascertain when appeared in DSM classification, as “dysmorphopho-
a false belief reaches delusional intensity. bia,” in DSM-III. The name was revised to the current
one in DSM-III-R.
Prognosis
Epidemiology
Hypochondriasis tends to have a chronic, waxing and
waning course; it has been described as having a BDD most commonly develops during adolescence.
“traitlike” character. Higher socioeconomic status, Reliable information about prevalence does not exist,
acute onset, the absence of comorbid personality dis- but preliminary evidence suggests that the disorder
order, and the absence of secondary gain are favorable occurs at equal rates in men and women.
prognostic signs.
Etiology
Treatment
The common family association of BDD with mood
As with other somatoform disorders, the appropriate disorders and obsessive-compulsive disorder (OCD),
management of hypochondriasis entails diagnosis and as well as its reported responsiveness to SSRIs, sug-
treatment of comorbid psychiatric conditions, proper gests that the disorder may stem from abnormalities in
handling of genuine comorbid medical conditions, serotonin physiology. It has also been suggested that
and avoidance of unnecessary tests and procedures. prevailing cultural expectations of “ideal” body parts
Studies support the efficacy of cognitive-behavioral may also be contributory.
approaches in the treatment of hypochondriasis. More
research is needed to evaluate the role of SSRIs in Clinical Features
hypochondriasis, but they are useful in treating com-
mon comorbid conditions such as depression, panic Individuals with BDD commonly are tormented by
disorder, or obsessive-compulsive disorder. The gen- their imagined defects in appearance, and not infre-
eral guidelines suggested for somatization disorder quently are encountered in plastic surgery clinics, as
may be useful for hypochondriasis. Again, trying to they endeavor to have such anomalies corrected.
argue patients out of their beliefs in illness is unlikely Reported patients have been described as shy, self-
to be successful. absorbed, and highly sensitive to criticism. The
families of individuals with BDD have a relatively
high prevalence of mood disorders and OCD, and
the condition often is comorbid with mood and anx-
iety disorders.
Individuals with BDD differ from those with OCD

inasmuch as the former do not view their recurrent
preoccupations as unreasonable; that is, they truly
have no insight and believe that their problem is
purely anatomical (some have viewed BDD as a vari-
ant of OCD, with no insight). It is important to note

21. Somatoform Disorder Not
Otherwise Specified
that the diagnosis of BDD, in contrast to that of Somatoform disorder not otherwise specified (NOS)
hypochondriasis, does not require that the false belief encompasses somatoform symptoms that do not meet
falls short of delusional intensity. However, isolated the criteria for any specific somatoform disorder. This
somatic delusions unrelated to appearance are better includes unexplained physical complaints or
accounted for by the diagnosis of delusional disorder. hypochondriacal concerns that last for <6 months.
Prognosis The most famous example of this diagnosis is pseudo-

cyesis, or false belief in being pregnant. Pseudocyesis
BDD most often begins in adolescence or early adult- may be marked by abdominal enlargement, amenor-
hood, and may have a gradual onset. It tends to have a rhea, subjective reports of fetal movement, breast
chronic and fluctuating course, and symptoms may engorgement and secretions, and “labor pains” at the
reappear, sometimes associated with a different body expected time of delivery. Endocrine changes may
part, after an imagined physical anomaly has been sur- even occur that are not fully explained by a medical
gically “corrected.” condition.
Treatment Cases of somatoform disorder NOS are necessarily

variable. Little empirical information being available,
Although psychotherapy has been viewed as ineffec- etiology, prognosis, and treatment are presumed to be
tive in treating BDD, except in a general and support- similar to that associated with somatization disorder.
ive sense, contolled trials support the efficacy of cog-
nitive-behavioral approaches as well as SSRIs. There
have been case reports of successful treatment with
tricyclic antidepressants, monoamine oxidase
inhibitors, and pimozide (the latter is held by some to
be uniquely effective in cases where delusions of para-
sitosis and infestation are involved, although there is
no well-designed study which demonstrates this).
Often, some degree of bodily preoccupation persists,
and almost inevitably, relapse occurs after medication
is discontinued.
22. Psychological Factors
Affecting Medical Condition
A large and fluctuating number of disorders of some- believed that specific personality types of psychologi-
times uncertain status occupy the interface of psychia- cal conflicts correlate with particular diseases. For the
try and the rest of medicine. The notion of interactions most part, it is held that psychological factors do not
between emotions and medical illnesses has existed cause medical disorders, but may profoundly affect
since ancient times, and was consistent with theories the suffering and disability associated with them.
of Hippocrates and Galen. Descartes is almost univer- Behavioral medicine is the discipline concerned with
sally reviled for allegedly positing a split between the impact of subjective experience as well as behav-
mind and body, but he did postulate that the mind (or ior upon medical illness.
soul) does interact with the body, albeit through the
pineal gland. The term “psychosomatic” dates from The DSM-III and DSM-IV replaced the previous term
the early 19th century, when psychiatrists of the “psychophysiologic disorders” with the current psy-
Romantic era, such as Johann Heilroth, placed greater chological factors affecting medical condition
emphasis on emotional states. (PFAMC). The diagnosis contains specifiers such as
mental disorders, psychologic symptoms, personality
In 1927, Walter Cannon demonstrated the autonomic traits or coping styles, maladaptive health behaviors,
correlates of some emotions. In 1934, Franz Alexan- or stress-related physiologic responses, any or all of
der, extending a psychoanalytic tradition, postulated which may affect a medical condition.
that particular types of unconscious conflicts gave
rise to corresponding medical illnesses, of which he The category is distinguished from the somatoform
specified a “classic” seven: rheumatoid arthritis, disorders in that the latter are not associated with a
essential hypertension, hyperthyroidism, peptic diagnosable medical condition that may account for
ulcer, ulcerative colitis, asthma, and neurodermatitis. symptoms. The DSM-IV requires that when PFAMC
In 1934, Hans Selye borrowed the physics term is diagnosed on Axis I, the associated medical condi-
“stress” to describe that which provokes a general tion should be listed under Axis III. Several conditions
adaptation syndrome, accompanied by increases in currently prominent in the field of “psychosomatic
adrenal cortical hormones and other endocrine medicine” (a term that is retained for convenience) are
changes. In 1936, Helen Flanders Dunbar introduced discussed below.
what later would become known as the “type A per-
sonality” and its hypothesized relationship to coro- Coronary Artery Disease
nary artery disease (CAD).
The so-called type A personality, comprising ele-
In the last few decades, the theory of mind-body inter- ments of perfectionism, competitiveness, anger, and
actions has become widely supported as a cliché. It is an urgent need for control, has long been associated
known that emotional stress may affect the course of with CAD. In recent years, it has become clear that
virtually any medical disorder; studies in psychoneu- hostility, more than the whole personality type, is
roimmunology and psychoneuroendocrinology have correlated with an increased risk of CAD. Hostility
demonstrated how such may occur. For example, is associated with increased atherosclerosis, higher
nerve endings are known to exist in various lymphoid risk of coronary vasospasm, and greater likelihood
and other immune tissues. The intimate relationship of cigarette smoking. Techniques aimed at stress
of the brain with the endocrine system, by means of reduction in those with competitive hostility have
the pituitary gland, is well known, and corticosteroid been shown to substantially reduce the risk of
receptors in the hippocampus and other brain areas are myocardial infarction.
believed to provide feedback information. Bereaved
spouses, as well as students taking a stressful exami- Depressive disorders also are known to increase risk
nation, have been shown to have reduced lymphocyte for CAD. Major depressive episodes are common
mitogen responses. Untreated psychiatric conditions, after myocardial infarction and clearly interfere with
particularly mood and anxiety disorders, may exacer- recovery. Life stress has also been demonstrated to
bate the course of any medical disorder. However, it increase the risk of sudden cardiac death from ventric-
should be noted that with the possible exception of the ular arrhythmias and other causes.
concept of type A personality, it is generally no longer

Irritable Bowel Syndrome Chronic Fatigue Syndrome
Irritable bowel syndrome (IBS), along with the In the early 1980s, there were an increased and fre-
related “nonulcer dyspepsia,” is the most common quent number of reports of individuals with unex-
“functional” gastrointestinal illness. Its generally plained persistent tiredness associated with various
accepted diagnostic criteria consist of >3 months of somatic complaints. In 1988, the Centers for Disease
abdominal pain or discomfort, relieved with defeca- Control (CDC) endorsed the diagnosis of chronic
tion or associated with a change in frequency or con- fatigue syndrome (CFS). The currently accepted cri-
sistency of stools, and an irregular pattern of defeca- teria, developed in 1994, consist of unexplained
tion at least 25% of the time, entailing >3 of the fol- fatigue for >6 months that is of new onset, not due to
lowing: altered stool frequency, altered stool form, exertion, not resolved by rest, and functionally dis-
altered stool passage, passage of mucus, or bloating. abling, and in addition, >4 of the following 8 symp-
Patients with IBS also have a greater prevalence of toms: impaired memory or concentration, sore throat,
gastroesophageal reflux, dysphagia, globus sensa- tender lymph nodes, muscle pain, joint pain,
tion, and noncardiac chest pain. headaches, unrefreshing sleep, and postexertional
malaise lasting >24 hours.
IBS symptoms appear to be quite common, existing
in 10% to 20% of adults. However, only approxi- Complaints of fatigue are very common in the general
mately one third of sufferers seek medical attention population as well as in medical patients, but strictly
for their complaints. The disorder is slightly more defined CFS is rare. Women are affected twice as
common in women. often as men, and the disorder usually begins in early
adulthood. In Canada and the United Kingdom, the
The etiology of IBS is not clearly understood, and it disorder is often called “myalgic encephalomyelitis.”
may comprise a number of different physiologic dis-
orders. Studies have demonstrated altered motility or The etiology of CFS remains unknown. Many studies
visceral sensation in various regions of the small and seemed to point to the Epstein-Barr virus as the
large intestines, but abnormalities differ between indi- pathogen, but these were discounted, as were reports
viduals and groups, and no finding is universal in IBS of other viruses. A number of minor and nonspecific
samples. Mood and anxiety disorders, as well as over- immunologic and serologic changes have been noted
all distress, are more common in those patients with in individuals with CFS, but they are similar to those
IBS who seek medical attention for their complaints. associated with many major medical and psychiatric
But the numerous individuals whose IBS symptoms illnesses, and thus inconclusive. As many as 75% of
do not drive them to a physician do not have preva- CFS sufferers meet the criteria for comorbid psychi-
lence rates of psychiatric disorders that are higher than atric illness, mostly depression, but such individuals
the general population. Therefore, it is generally tend to be highly invested in their somatic complaints.
believed that psychological factors do not cause IBS, Many investigators have argued that CFS should be
per se, but they can profoundly influence the experi- considered a variant of mood disorder, or even a
ence and extent of illness. somatoform disorder. Concensus is lacking. An
appropriately focused medical evaluation is necessary
Aside from appropriate medical evaluation to rule out to eliminate causes of fatigue such as anemia, sleep
alternative causes of gastrointestinal symptoms, such disorder, or neoplasm.
as inflammatory bowel disease or neoplasm, as well as
treatment of comorbid psychiatric conditions, the As its name implies, CFS tends to persist, but some
treatment of IBS is purely symptomatic. Fiber supple- patients improve to some extent. Minimal psychiatric
ments, antispasmodic agents, antidiarrheal medica- comorbidity, good social support, and continuation of
tions, and prokinetic agents may be helpful. employment are correlated with a better prognosis.
Treatment of CFS generally is supportive and symp-
tomatic. In addition to analgesics, amantadine may
lessen fatigue. Trials of antidepressants in CFS have
had mixed results, although clearly comorbid depres-
sion requires aggressive treatment. Cognitive behav- Neurasthenia never disappeared from most of the rest
ioral treatment for CFS, including in a group setting, of the world, however, and remains an accepted diag-
has been shown to be of some benefit; it is analogous nosis in Europe and particularly in China and other
to similar treatments for chronic pain inasmuch as it east Asian countries. Medical anthropologists have
focuses on appraisals of discomfort and maximizing asserted that neurasthenia in China is a culturally
function. Graded exercise therapy also has evidence accepted code word for mood disorder, as depression
for efficacy. per se is rarely diagnosed there. Neurasthenia is a
diagnosis in ICD-10, having the criteria of 3 months’
Fibromyalgia duration of persistent and distressing fatigue after
either minor mental or physical effort, as well as at
Fibromyalgia is a syndrome of multiple sites of mus- least one of the following symptoms: muscle pains,
cle pain as well as tenderness of specific anatomical dizziness, tension headaches, sleep disturbance,
trigger points, as elicited by physical examination. inability to relax, or irritability. The diagnosis is
According to the American College of Rheumatology excluded if there is comorbid mood disorder, panic
in 1990, the diagnosis requires pain that is bilateral, disorder, or generalized anxiety disorder.
above and below the waist, and including the lower
back, chest, or upper spine; in addition, there must be Given the provisional status of the diagnosis of
11 of 18 (9 bilateral) possible trigger points. neurasthenia, as well as its widely considered overlap
with mood and anxiety disorder, etiology is difficult to
The diagnosis of fibromyalgia is of ambiguous status. determine. As the disorder’s name implies, some
Many patients and medical authorities claim it as a diminution of nervous system function, perhaps
discrete diagnosis, but critics argue that it is a variant through depletion of neurotransmitters, is suspected.
of CFS or psychiatric disorder. A significant number Treatment is similar to that recommended for CFS
of fibromyalgia sufferers also meet the criteria for and fibromyalgia.
CFS and vice versa, and mood disorders are highly
prevalent among those with fibromyalgia. As with
CFS, treatment is symptomatic, and antidepressants
are helpful in some cases. Exercise programs have
been shown to have some efficacy.
Neurasthenia
The American physician, George Beard, coined the

term “neurasthenia” in 1869 to refer to a syndrome of
mental and physical exhaustion, often accompanied by
frequent pains and soreness and resulting disability,
that he considered quite common in the United States
and Europe at that time. The diagnosis was accepted
and frequently used in the late 19th century. Around
the turn of the century, medical authorities began to
doubt the diagnosis and to maintain that, in most cases,
it was due to psychological factors. Thereafter, neuras-
thenia mostly vanished from American psychiatric
nosology, although some have argued that CFS is noth-
ing other than a latter-day form of the same illness.
Neurasthenia is briefly mentioned in DSM-IV, but is
subsumed under the category of undifferentiated
somatoform disorder.

23. Factitious Disorders
Factitious disorder and factitious disorder NOS con- compulsion exists as well. Inasmuch as they seem to be
stitute the factitious disorders, the hallmark of which in control and out of control at the same time, they
is the intentional feigning of physical or psychologi- alternate between abject dependency and contemptu-
cal symptoms for no other purpose than to assume ous superiority with respect to ambivalently viewed
the sick role. authority figures. Comorbid personality disorders, and
especially borderline personality disorder, are com-
Factitious Disorder mon. It is speculated that patients with factitious disor-
der seek to construct an identity as a patient because
Definition they can achieve no other.
Factitious disorder in DSM-IV has three possible
specifiers, depending on whether fabricated symp- Clinical Features
toms are psychological, physical, or both. Descrip- Psychological symptoms that are faked in factitious dis-
tions of feigned illness have existed since ancient order may include hallucinations, delusions, suicidality,
times, but only in the 20th century did that which and cognitive deficits. It is often extremely difficult to
would come to be called factitious disorder begin to be demonstrate that the complaints are false. Only marked
well differentiated from malingering. In 1951, Asher inconsistencies in history and mental status examina-
famously devised the sobriquet “Munchausen syn- tion are reliable cues, and often the diagnosis remains
drome” to identify a type of factitious disorder marked provisional. An invalid score on the Minnesota Multi-
by chronicity and a tendency of afflicted individuals to phasic Personality Inventory may suggest that an indi-
wander from hospital to hospital in search of diagnos- vidual is trying to exaggerate pathology. Patients may
tic procedures. Over time, it became apparent that not undergo lengthy hospitalizations and tolerate large
all factitious illness is so chronic or colorful, and the doses of psychotropic medication and even ECT in an
more general term “factitious disorder” was adopted. effort to seem ill. Patients who feign psychological
“Munchausen syndrome” remains in frequent usage, symptoms tend to have above average intelligence, to
however, to refer to particularly chronic and severe be markedly dependent and narcissistic, and to have
factitious illness or, mistakenly, to denote any degree high rates of borderline personality disorder.
of factitious disorder.
Countless gruesome tales have derived from physical
Epidemiology symptoms feigned in factitious disorder. Patients
Reliable information about prevalence is unavail- eagerly undergo any number of invasive diagnostic
able. The diagnosis is rarely made, but the milder tests and even operations. Individuals have ingested
forms of factitious disorder may be underrecog- anticoagulants to induce bleeding, injected insulin to
nized. The disorder most commonly begins in early induce hypoglycemia, and infused themselves with
to mid-adulthood, and women are affected signifi- bacteria or feces to induce fever. The phenomenon
cantly more often than men. tends to be intensely surreptitious, and if the actuality
of symptoms is questioned, individuals often become
Etiology enraged and contemptuous. Even when confronted
Many have speculated about the causes of the bizarre with evidence of their deception, they often will con-
behavior associated with factitious disorder. Many tinue to vehemently deny any wrongdoing.
patients with the disorder have previous or current con-
tact with the medical milieu, either as patients or as A history of wandering from hospital to hospital with
healthcare workers, or they have been closely involved melodramatic presentations may be a clue that facti-
with a family member or friend who has been seriously tious disorder should be considered. The diagnosis of
ill. The sado-masochistic nature of the experience has feigned psychological symptoms rests chiefly on
been noted—the patients accept serious and senseless inference. In the case of physical symptoms, it may be
risks to themselves, and yet underlying the disorder is a necessary to search a patient’s room, if possible. Hid-
tremendous resentment of and hostility toward the den supplies of unprescribed medication or syringes
medical setting. While the symptoms of factitious dis- constitute fairly conclusive evidence in most cases. In
order are voluntary, it is recognized that an element of certain situations, laboratory tests may be helpful.
24. A Note on Malingering
Prognosis Malingering is the voluntary fabrication of—or exag-

Factitious disorder may be limited to isolated geration of—physical or psychological symptoms for
episodes, but more commonly it is chronic. the purpose of obtaining some obvious, external goal,
such as money or freedom from responsibility. It is not
Treatment considered a mental disorder (in selected situations, it
No treatment for factitious disorder exists that is may be quite adaptive) and is classified in DSM-IV as
definitive by common consent or empirical proof. an “Additional Condition That May Be a Focus of
Most recommended approaches entail some kind of Clinical Attention,” with the code V65.2. It may coex-
confrontation of the patient with the diagnosis, neces- ist with actual mental or physical illnesses.
sarily in a supporting and nonaccusatory fashion,
often with subsequent psychiatric hospitalization. No Ganser’s syndrome is characterized by approximate
medication is specifically helpful for the disorder; but false answers to questions, such as an answer of
psychotherapy based on both psychodynamic and “9” to “What is 5 + 5?” In DSM-IV, it is classified as
behavioral approaches has been endorsed. The avoid- an example of dissociative disorder NOS, although
ance of unnecessary and potentially harmful medical many consider it to be a form of malingering in most
procedures is necessary, as is treatment of comorbid contexts.
medical and psychiatric conditions.
Factitious Disorder Not

Otherwise Specified
Factitious disorder NOS consists chiefly of factitious

disorder by proxy, for which suggested research crite-
ria exist in DSM-IV. Factitious disorder by proxy
entails the intentional production of physical or psy-
chological signs or symptoms in another person who
is under an individual’s care. In the great majority of
cases, the victim is a child and the perpetrator is the
child’s mother, although fathers may be involved as
well, and the victim may be an elderly person or other
adult. Analogous to factitious disorder, the condition
may entail the injection of medications, contaminated
material, or other substances to induce bleeding,
infection, or other apparent disorders in the victim.
Factitious disorder by proxy is considered to consti-

tute child abuse (or spouse or elder abuse, if applica-
ble); therefore, confrontation of the perpetrator and
appropriate protection of the victim are necessary. The
perpetrators often have factitious disorder themselves,
and tend to desperately conceal and deny their
involvement.
The prevalence of factitious disorder by proxy is

unknown. Its etiology, prognosis, and treatment are
presumed to be very similar to those of factitious
disorder.

25. Legal Issues
Medicolegal questions often arise in the context of Battery is the performance of a procedure in a medical
consultation psychiatry. Although the specifics of setting without the consent of the patient.
law vary from place to place, some general princi-
ples apply in nearly all jurisdictions. These princi- Informed consent is the process by which a compe-
ples apply to both physicians’ and patients’ rights. tent patient agrees to a procedure. Once the patient
is given information regarding the risks and benefits
Malpractice law is a type of tort law concerning of the procedure, consent is given. The three compo-
injuries allegedly caused by professionals in the pro- nents of informed consent are information, compe-
cess of providing a treatment. To prove malpractice, tence, and consent. A patient can waive the
four things must be shown. First, the defendant owed informed part of the consent if he or she so desires.
a duty to the injured person. Next, the physician Informed consent is not necessary in the event of
failed to practice according to the standards of the emergency where any delay in treatment would be
average physician in the community and was there- life threatening.
fore negligent. Finally, damages are proven and the
negligent behavior is shown to be the direct cause of Competency is an issue that frequently comes up in
such damages. If each of these elements is found to the psychiatry consultation service. Competency is
be true, then the defendant can be held liable and defined as the legal capacity to perform a function.
forced to pay damages to the plaintiff. The top rea- This definition implies that a patient may be compe-
son for claims against psychiatrists is suicide. tent in one function, but not in another. For example,
a patient may have decision-making capacity for
Confidentiality is the physician’s obligation to keep health care, but may not have testamentary capac-
patient information from third parties. Exceptions to ity. All adults are assumed competent. To prove
this obligation exist when maintaining confidentiality competence in healthcare decision-making, a
will cause more harm than good. The most famous patient must understand his or her illness, under-
example of such an exception comes from the 1976 stand the proposed treatment options, understand
case of Tarasoff vs. Board of Regents. The ruling in the consequences of choosing one treatment option
this case affirmed that psychotherapists have a duty to over another, and have adequate judgment to use
protect third parties in the event that the therapist this information. Psychiatric illnesses such as delir-
becomes aware that the patient represents a danger to ium, dementia, and depression can cloud the ques-
the third party. Another universal exception to confi- tion of competence, but none is ever an absolute
dentiality is the requirement that all cases of known indication of incompetence. Only a court can offi-
or suspected child abuse be reported to state agencies. cially declare a person incompetent, but a psychia-
A more recent challenge to the rules of confidential- trist can comment on capacity to perform various
ity is seen in the case of HIV. If the physician knows activities. Patients can delegate a decision-maker
that a patient is infected and has not told sexual part- by naming a durable power of attorney. The durable
ners, then the physician may break confidentiality power of attorney will serve as a surrogate deci-
rules to warn the sexual partners. sion-maker in the event that the patient loses deci-
sion-making capacity.
Privilege is the right of a patient to exclude testimony
about information that has been revealed to a physi- Civil commitment is the process by which the state uses
cian in the course of a professional relationship. its power to remove a patient from society and place
him or her in a hospital setting. The principle motivat-
Right of treatment refusal is accorded to all competent ing commitment is the state’s responsibility to maintain
individuals. In 1996 in Cruzan vs. Missouri Depart- law and order in response to the perceived dangerous-
ment of Public Health, the Supreme Court deemed this ness of a patient. A patient can, therefore, be involuntar-
to be true in the case of refusal of life-sustaining treat- ily committed if he or she poses a danger to herself
ment. In the case of the incompetent patient, the state directly (eg,through suicide), if he or she poses a direct
can voice its interest in preservation of life and requires danger to another (eg, through homicidal threat), or if
clear evidence of the patient’s prior preferences before the individual is so disabled that he or she cannot ade-
any surrogate can refuse on behalf of the patient. quately care for himself or herself in society.
26. Questions
Use of restraint on the psychiatric or medical floors is 1. Which of the following most clearly describes a
generally allowed to protect the patient or staff, or for case of factitious disorder?
the purpose of treatment when the patient refuses.
A. A middle-aged woman with vague joint com-
Forced treatment should be reserved for an emergency
plaints is found to be involved in a class-action
situation. In the absence of such an emergency,
lawsuit against a breast implant manufacturer.
attempts should be made to obtain surrogate consent
B. A teenage boy living on a farm develops apho-
in the case of the patient who lacks decision-making
nia after his father dies suddenly.
capacity.
C. A young woman has a year-long history of
fatigue and headaches and has had a negative
medical work-up.
D. Contaminated syringes are found beneath the
mattress of a young man with a central venous
catheter infection.
E. An elderly woman with chronic headaches and
a normal CT scan of the head is convinced that
she has a brain tumor.
2. In which of the following scenarios would it be

most reasonable to consider fluoxetine as a first-
line treatment?
A. A 44-year-old woman with diabetes develops a
painful neuropathy.
B. A 24-year-old accountant is tormented by a
conviction that his head (which appears to be
of normal size) is embarrassingly large.
C. A 30-year-old man has repeated visits to his
physician for complaints of severe incapacitat-
ing neck and back pain which he attributes to a
recent motor vehicle accident. As a result, he is
unable to work and is receiving disability pay-
ments. No medical cause for the severe pain
has been found despite repeated evaluations.
The patient is awaiting a court date for a large
lawsuit against the driver causing his accident.
D. A 49-year-old man who has never served in the
military fabricates stories of tours of duty in
Vietnam in order to obtain veterans’ benefits.
E. A 30-year-old woman experiences lower
extremity numbness whenever her husband
talks to her about their plans to have children.
3. You are called to see a 70-year-old woman on the

oncology service who has a history of metastatic
breast cancer and was admitted with mental status
changes. After completing your examination, you
determine that she is delirious. Her vital signs are
within normal limits and she has no history of
fever. She has had no recent changes in medication,
but is chronically maintained on fentanyl patches at

a dose of 150 µg/day. On hospital admission, labora- 5. The first line of treatment for HIV-associated
tory analyses show Hct 35, WBC 8.0, Plts 150, Na 137, dementia is :
BUN 15, Creat 1.0, Ca 11.5, and albumin 1.5. Urinaly-
sis is unremarkable. A noncontrasted head CT and A. Bupropion
chest radiograph obtained on admission are normal. B. Zidovudine
What is the most likely cause of her delirium? C. Tacrine
D. Trazodone
A. Hypoxia
E. Lithium carbonate
B. Hypercalcemia
C. Alcohol withdrawal
6. A patient with a chronic central pain state is being
D. Meningitis
treated with methadone but continues to experi-
E. Fentanyl effect
ence pain. Which of the following would you be
least likely to recommend?
4. You are asked to evaluate a patient’s capacity for
decision-making. The patient is a 30-year-old A. Increase the dose of methadone
man with AIDS, CD4 count 100, HIV RNA viral B. Carbamazepine
load 100,000 who is currently on a triple drug C. Gabapentin
regimen for his HIV disease. He was previously D. Amitriptyline
diagnosed with HIV-associated dementia, but
was able to live independently before admission. 7. Which of the following medications will not cause
He was admitted to the hospital because of delirium in a medically ill elderly patient?
severe abdominal pain and was found to have a
A. Amitriptyline
small bowel obstruction. The recommendation
B. Meperidine
of the treatment team is that he be taken to
C. Ibuprofen
surgery for resection of the obstruction. The
D. Alprazolam
patient tells you that he has a blockage in his
E. All of the above can cause delirium
intestine that the doctors want to fix and that he
may die if he does not have the surgery, but that
he does not want to proceed with surgery. He
states that he does not want the surgeon to look
at his intestine because the surgeon might learn Answers
that he is truly a cat and not a human. What do 1. D Section 23
you recommend to the treating team?
2. B Section 20
A. The patient is not competent to give informed
consent because of his prior diagnosis of HIV- 3. B Section 4
associated dementia. 4. D Section 25
B. The patient is able to understand the procedure,
its risks, and benefits and is, therefore, compe- 5. B Section 11
tent to refuse the treatment. 6. A Section 8
C. The patient is not a surgical candidate because
of his AIDS and HIV-associated dementia. 7. E Section 4
D. The patient is not able to give informed consent
because of a delusional belief.
E. Despite the presence of a delusion, the patient
is able to give informed consent because he
understands the nature of his illness, the nature
of the treatment, and the consequences of
refusing or accepting treatment.
27. References
1. American Psychiatric Association, Diagnostic 11. Cohen-Cole SA, Stoudemire A. Major depres-
and Statistical Manual of Mental Disorders. sion and physical illness; special considerations
Fourth Edition, Text Revision, Washington, DC: in diagnosis and biologic treatment. Psychiatr
American Psychiatric Press, 2000. Clin North Am. 10:1:1-17, 1987.
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Functional somatic symptoms and somatoform psychiatry: An examination of ethical issues and
disorders. In: Massachusetts General Hospital professional guidelines. Psychosomatics. 36:12-
Handbook of General Hospital Psychiatry. Fourth 21, 1995.
Edition. St Louis, MO: Mosby, 1997.
13. Egan MF, Hyde TM, Albers GW, et al. Treatment
3. Burch WM. Endocrinology for the House Officer. of tardive dyskinesia with vitamin E. Am J Psy-
Second Edition. Baltimore, MD: Williams & chiatry. 149:773-777, 1992.
Wilkins, 1988.
14. Fauci AS, Braunwald E, Isselbacher KJ, Kasper
4. Busch A, Schacter CL, Peloso PM, Bombardier DL, Hauser SL (Eds). Harrison’s Textbook of
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15. Fricchione GL, Carbone L, Bennett WI. Psy-
5. Carbone JR, The Neuroleptic Malignant and chotic disorder caused by a general medical con-
Serotonin Syndromes. Emergency Medicine dition, with delusions. Psychiatr Clin North Am.
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6. Carpenter CC, Fischl MA, Hammer SM, et al. 16. Fukada K, Straus SE, Hickie I, et al. The chronic
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Updated recommendations of the International its definition and study. Ann Intern Med. 121:953-
AIDS Society-USA Panel. JAMA. 280:78-86, 959, 1994.
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17. Garrick TR, Stotland NL. How to write a psychi-
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MS (Eds). Massachusetts General Hospital 855, 1982.
Handbook of General Hospital Psychiatry. Fourth
Edition. St Louis, MO: Mosby-Year Book, 1997. 18. Gelfand SB, Indelicato J, Benjamin J. Using
intravenous haloperidol to control delirium. Hosp
8. Cassem NH (Ed). Massachusetts General Hospi- and Community Psychiatry. 43:3:215, 1992.
tal Handbook of General Hospital Psychiatry.
Third Edition. St Louis, MO, Mosby-Year Book, 19. Glassman, AH, O’Connor CM, Califf, RM Glass-
1991 man AH. O’Connor CM. et al. Sertraline Antide-
pressant Heart Attack Randomized Trial (SAD-
9. Cohen LS. Update on Reproductive Safety of HEART) Group. Sertraline treatment of major
Psychotropic Medications, Part I. Currents in depression in patients with acute MI or unstable
Affective Illness. 20:5:5-11, 2001. angina. JAMA. 288(6):701-9, 2002.
10. Cohen LS. Update on Reproductive Safety of 20. Groves JE. Difficult patients. In Massachusetts
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Mosby, 1997.

21. Kaplan HI, Sadock BJ. Comprehensive Textbook 33. Wise MG, Rundell JR. Concise Guide to Consul-
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22. Lipowski ZJ. Somatization: The concept and its 34. Yeni PG, Hammer SM, Carpenter CC et al.
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North Am. 15:2:335-346, 1992.
24. Lynn RB, Friedman LS. Irritable bowel syn-

drome. N Engl J Med. 329:1940-1945, 1993.
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tion. AIDS. 4:831-840, 1990.
26 Max MB, Lynch SA, Muir J, et al. Effects of

desipramine, amitriptyline, and fluoxetine on pain
in diabetic neuropathy. N Engl J Med. 326:1250-
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Consultation-Liaison

1. Introduction 14. Somatoform Disorders

2. Anxiety and Medical Conditions 15. Somatization Disorder

3. Depression and Medical Conditions 16. Undifferentiated Somatoform

6. Personality Change Due to a General 19. Hypochondriasis

9. Psychopharmacology in the Medically 22. Psychological Factors Affecting

10. Transplantation Issues 23. Factitious Disorders

11. Medical Illness Presenting With 24. A Note on Malingering

13. Drug Intoxication and Overdose 27. References

A consultation begins with a question from a referring

Next, the patient is interviewed at the bedside. In cases

2 EDUCATIONAL REVIEW MANUAL IN PSYCHIATRY

Panic disorder probably is the most recognized anxi-

4 EDUCATIONAL REVIEW MANUAL IN PSYCHIATRY

In the first instance, four approaches have been

6 EDUCATIONAL REVIEW MANUAL IN PSYCHIATRY

Intracranial bleeding or infection

From: Wise and Rundell. Concise Guide to Consultation

Infection Encephalitis, meningitis, syphilis, human immunodeficiency virus, sepsis

Withdrawal Alcohol, barbiturates, sedative-hypnotics

Acute metabolic Acidosis, alkalosis, electrolyte disturbance, hepatic or renal failure

Trauma Closed-head injury, heatstroke, postoperative, severe burns

Central nervous system Abscess, hemorrhage, hydrocephalus, subdural hematoma,

Hypoxia Anemia, CO poisoning, hypotension, pulmonary or cardiac failure

Deficiencies Vitamin B12, folate, niacin, thiamine

Endocrinopathies Hyper-/hypoadrenocorticism, hyper-/hypoglycemia, myxedema,

Acute vascular Hypertensive encephalopathy, stroke, arrhythmia, shock

Toxins or drugs Medications, illicit drugs, pesticides, solven

Heavy metals Lead, manganese, mercury

From APA textbook of Consultation-Liaison Psychiatry.

8 EDUCATIONAL REVIEW MANUAL IN PSYCHIATRY

Medications Which May be Associated with Delirium

Acetylcholinesterase Inhibitors Disulfiram Phenylephrine

Some authorities recommend treating delirium with

For delirious patients requiring narcotics for pain,

Psychosocial interventions will not successfully treat

10 EDUCATIONAL REVIEW MANUAL IN PSYCHIATRY

12 EDUCATIONAL REVIEW MANUAL IN PSYCHIATRY

patients, particularly thioridazine in the typical class, Approach to the Patient

14 EDUCATIONAL REVIEW MANUAL IN PSYCHIATRY

Placebo Effect Somatization disorder consists of multiple pain com-

16 EDUCATIONAL REVIEW MANUAL IN PSYCHIATRY

Seizure Disorders Fetal exposure to some benzodiazepines during the

18 EDUCATIONAL REVIEW MANUAL IN PSYCHIATRY

recurrent depression is doing well on an antidepres- Psychiatrists may be part of a multidisciplinary

organ transplantation unless they can successfully Endocrine Disorders

20 EDUCATIONAL REVIEW MANUAL IN PSYCHIATRY

22 EDUCATIONAL REVIEW MANUAL IN PSYCHIATRY

24 EDUCATIONAL REVIEW MANUAL IN PSYCHIATRY

HIV-MND and HAD are forms of subcortical disease.

Zidovudine Retrovir Fatigue, nausea, headache,

Lamivudine Epivir Insomnia, malaise, headache,

Didanosine Videx, ddI Insomnia, mania, peripheral

Stavudine Zerit, d4T Mania, peripheral neuropathy,

Abacavir Ziagen Insomnia, headache, anorexia

Indinavir Crixivan Kidney stones

Saquinavir Invirase Asthenia, hyperglycemia, nausea

Ritonavir Norvir Perioral numbness, asthenia

Nelfinavir Viracept Fatigue, headache, decreased