Psychiatric secrets 2nd ed

Preface to First EditionPreface to Second Edition Section One - APPROACH TO CLINICAL INTERVIEWING AND DIAGNOSIS Section Two - DIAGNOSTIC PROCEDURES Section Three - PRINCIPAL CLINICAL DIS

Psychiatric Secrets (The Secrets Series) 2nd edition (January 15, 2001) by James

L Jacobson (Editor), Alan Jacobson (Editor) By Hanley & Belfus;

By OkDoKeY

Preface to First Edition

Preface to Second Edition

Section One - APPROACH TO CLINICAL INTERVIEWING AND DIAGNOSIS Section Two - DIAGNOSTIC PROCEDURES

Section Three - PRINCIPAL CLINICAL DISORDERS AND PROBLEMS

Section Four - DEMENTIA, DELIRIUM, AND RELATED CONDITIONS

Section Five - PERSONALITY DISORDERS

Section Six - THERAPEUTIC APPROACHES IN PSYCHIATRY

Section Seven - DIAGNOSIS AND TREATMENT OF PSYCHIATRIC DISORDERS

IN CHILDHOOD AND ADOLESCENCE

Section Eight - DISORDERS ASSOCIATED WITH PREGNANCY AND

MENSTRUATION

Section Nine - GERIATRIC PSYCHIATRY

Section Ten - CONSULTATION-LIAISON PSYCHIATRY

Section Eleven - SPECIAL TREATMENT POPULATIONS

Section Twelve - ETHICAL AND LEGAL ISSUES IN PSYCHIATRY

Section One - APPROACH TO CLINICAL INTERVIEWING AND DIAGNOSIS

1 - THE INITIAL PSYCHIATRIC INTERVIEW

2 - THE MENTAL STATUS EXAMINATION

3 - ORGANIZATION AND PRESENTATION OF PSYCHIATRIC INFORMATION

4 - INTRODUCTION TO DSM-IV

Section Two - DIAGNOSTIC PROCEDURES

5 - PROJECTIVE TESTING

6 - NEUROPSYCHOLOGICAL TESTING

7 - SELF-REPORT QUESTIONNAIRES

8 - STANDARDIZED PSYCHIATRIC INTERVIEWS

9 - BRAIN IMAGING IN PSYCHIATRY

Section Three - PRINCIPAL CLINICAL DISORDERS AND PROBLEMS

10 - SCHIZOPHRENIA AND SCHIZOAFFECTIVE DISORDERS

11 - PARANOID DISORDERS

12 - BIPOLAR DISORDERS

13 - DEPRESSIVE DISORDERS

14 - PANIC ATTACKS AND PANIC DISORDER

15 - SOCIAL PHOBIA AND SPECIFIC PHOBIAS

16 - GENERALIZED ANXIETY DISORDER

17 - OBSESSIVE-COMPULSIVE DISORDERS

18 - POSTTRAUMATIC STRESS DISORDER

19 - PSYCHOACTIVE SUBSTANCE USE DISORDERS

20 - ALCOHOL USE DISORDERS

21 - OPIOID USE DISORDERS

22 - SEDATIVE-HYPNOTIC USE DISORDERS

23 - COCAINE AND AMPHETAMINE USE DISORDERS

24 - MARIJUANA, HALLUCINOGENS, PHENCYCLIDINE, AND INHALANTS

25 - DUAL DIAGNOSIS: SUBSTANCE ABUSE AND PSYCHIATRIC ILLNESS

26 - DISSOCIATIVE DISORDERS INCLUDING DISSOCIATIVE IDENTITY DISORDER (FORMERLY MULTIPLE PERSONALITY DISORDER)

27 - SEXUAL DISORDERS AND SEXUALITY

28 - EATING DISORDERS

29 - SLEEP DISORDERS IN PSYCHIATRIC PRACTICE

30 - IMPULSE-CONTROL DISORDERS

31 - MEDICALLY UNEXPLAINED SYMPTOMS

32 - GRIEF AND MOURNING

Section Four - DEMENTIA, DELIRIUM, AND RELATED CONDITIONS

33 - BEHAVIORAL PRESENTATIONS OF MEDICAL AND NEUROLOGIC DISORDERS

34 - DEMENTIA

35 - DELIRIUM

36 - PSYCHOSIS WITH NEUROLOGIC/SYSTEMIC DISORDERS

Section Five - PERSONALITY DISORDERS

37 - PERSONALITY AND PERSONALITY DISORDERS

38 - BORDERLINE PERSONALITY DISORDER

39 - ANTISOCIAL PERSONALITY DISORDER

Section Six - THERAPEUTIC APPROACHES IN PSYCHIATRY

40 - PSYCHOANALYTICALLY ORIENTED PSYCHOTHERAPIES

41 - COGNITIVE-BEHAVIORAL THERAPY

42 - BEHAVIOR THERAPY

43 - PLANNED BRIEF PSYCHOTHERAPY

44 - MARITAL AND FAMILY THERAPIES

52 - THE USE OF STIMULANTS IN PSYCHIATRIC PRACTICE

53 - UNDERSTANDING MEDICATION INTERACTIONS

54 - ELECTROCONVULSIVE THERAPY

Section Seven - DIAGNOSIS AND TREATMENT OF PSYCHIATRIC DISORDERS

IN CHILDHOOD AND ADOLESCENCE

55 - AUTISM SPECTRUM DISORDERS

56 - ATTENTION DEFICIT-HYPERACTIVITY DISORDER

57 - CONDUCT DISORDER

58 - OBSESSIVE-COMPULSIVE DISORDER IN CHILDREN AND

ADOLESCENTS

59 - ENCOPRESIS AND ENURESIS

60 - ADOLESCENT DRUG ABUSE

61 - PRINCIPLES OF CHILD AND ADOLESCENT PSYCHOPHARMACOLOGY

Section Eight - DISORDERS ASSOCIATED WITH PREGNANCY AND MENSTRUATION

62 - PREMENSTRUAL SYNDROME AND PREMENSTRUAL DYSPHORIC DISORDER

63 - PSYCHIATRIC DISORDERS AND PREGNANCY

64 - POSTPARTUM PSYCHIATRIC DISORDERS

Section Nine - GERIATRIC PSYCHIATRY

65 - DEVELOPMENTAL ISSUES IN LATE LIFE

66 - PSYCHOPHARMACOLOGY FOR ELDERLY PATIENTS

Section Ten - CONSULTATION-LIAISON PSYCHIATRY

67 - PSYCHIATRIC CONSULTATION IN THE GENERAL HOSPITAL

68 - PSYCHIATRIC DISORDERS IN PRIMARY CARE SETTINGS

69 - THE MANAGEMENT OF CHRONIC PAIN

70 - THE ASSESSMENT AND TREATMENT OF SEXUAL DYSFUNCTION

71 - PSYCHIATRIC ASPECTS OF AIDS

72 - PSYCHIATRIC CONSULTATION IN PATIENTS WITH CARDIOVASCULAR DISEASE

73 - CONSULTATION FOR THE CANCER PATIENT

74 - PSYCHOLOGICAL PERSPECTIVES IN THE CARE OF PATIENTS WITH DIABETES MELLITUS

Section Eleven - SPECIAL TREATMENT POPULATIONS

75 - SUICIDE: RISK FACTORS AND MANAGEMENT

76 - ASSESSMENT AND MANAGEMENT OF THE VIOLENT PATIENT

77 - NEUROLEPTIC MALIGNANT SYNDROME

78 - TREATMENT-RESISTANT DEPRESSION

79 - OBESITY

Section Twelve - ETHICAL AND LEGAL ISSUES IN PSYCHIATRY

80 - CONFIDENTIALITY AND PRIVILEGE

81 - LEGAL RESPONSIBILITIES WITH CHILD ABUSE AND DOMESTIC VIOLENCE

82 - INVOLUNTARY TREATMENT: HOSPITALIZATION AND MEDICATIONS

83 - COMPETENCE AND INSANITY

84 - ETHICS AND THE DOCTOR-PATIENT RELATIONSHIP

Harvard Medical School

Senior Vice President

Web site: http://www.hanleyandbelfus.com

Note to the reader:

Although the information in this book has been carefully reviewed for correctness of dosage and indications, neither the authors nor the editor nor the publisher can accept any legal responsibility for any errors or omissions that may be made Neither the publisher nor the editor makes any warranty, expressed or implied, with respect to the material contained herein Before prescribing any drug, the reader must review the manufacturer’s current product information (package inserts) for accepted indications, absolute dosage recommendations, and other information pertinent to the safe and effective use of the product described

Library of Congress Cataloging-in-Publication Data

Psychiatric secrets / written [i.e edited] by James L Jacobson, Alan M Jacobson.—2nd ed

p ; cm — (The Secrets Series® )

Includes bibliographical references and index

ISBN 1-56053-418-4 (alk paper)

1 Psychiatry—Examinations, questions, etc I Jacobson, James L., 1951–

II Jacobson, Alan (Alan M.) III Series

[DNLM: 1 Mental Disorders—diagnosis—Examination Questions 2 Mental

Disorders—therapy—Examination Questions WM 18.2 P9727 2000]

RC457.P76 2001

616.89'0076—dc21

00-037043

PSYCHIATRIC SECRETS, 2nd ed ISBN 1-56053-418-4

© 2001 by Hanley & Belfus, Inc All rights reserved No part of this book may be

reproduced, reused, republished, or transmitted in any form, or stored in a data base or

retrieval system, without written permission of the publisher.Last digit is the print number: 9 8 7 6 5 4 3 2 1

VIII

Rochester, New York

Mark A Blais PsyD

Assistant Professor,

Department of Psychiatry,

Harvard Medical School;

Associate Chief of Psychology,

Massachusetts General Hospital

Harvard Medical School, Boston;

Program in Psychiatry and the Law, Massachusetts Mental Health CenterBoston, Massachusetts

Clinical Fellow in Psychiatry,

Harvard Medical School, Boston;

Fellow in Psychosocial Oncology,

Dana Farber Cancer Institute

Boston, Massachusetts

C Munro Cullum PhD

Associate Professor,

Departments of Psychiatry and Neurology,

University of Texas Southwestern Medical CenterDallas, Texas

Robert D Davies MD

Assistant Professor,

Department of Psychiatry;

Director,

Anxiety and Mood Disorders Clinic,

University of Colorado Health Sciences CenterDenver, Colorado

Professor Emeritus of Psychiatry,

University of Colorado School of Medicine

Denver, Colorado

Christopher M Filley MD

Professor of Neurology and Psychiatry,

University of Colorado School of Medicine, Denver; Attending Physician,

Denver Veterans Affairs Medical Center

Associate Clinical Professor of Psychiatry,

University of Colorado Health Sciences Center; Medical Director,

Colorado Physicians’ Health Program

Denver, Colorado

Alexis A Giese MD

Associate Professor,

Department of Psychiatry,

University of Colorado Health Sciences Center

Denver, Colorado

Benjamin P Green MD

Assistant Clinical Professor of Psychiatry,

University of Colorado School of Medicine;

Private Practice (psychiatry)

Harvard Medical School, Boston;

Senior Vice President,

Strategic Health Initiatives,

Joslin Diabetes Center

Harvard Medical School, Boston;

Associate Chief of Psychiatry Research, Massachusetts General Hospital

Associate Professor of Medicine and Psychiatry, University of Colorado Health Sciences CenterDenver, Colorado

Mary Lou Klem PhD

Consolidated Department of Psychiatry,

Harvard Medical School, Fall River;

Senior Psychiatrist,

Massachusetts General Hospital

Weill Medical College of Cornell University

New York, New York

Robin April McCann PhD

Division Chief Psychologist,

Institute for Forensic Psychology,

Colorado Mental Health Institute

Clinical Pharmacy Practice,

University of Colorado School of PharmacyDenver, Colorado

William H Redd MD

Professor,

Mt Sinai School of Medicine, New York;

Associate Director,

Ruttenberg Cancer Center,

Mt Sinai/New York University Medical School

New York, New York

Division of Substance Dependence,

University of Colorado School of Medicine

Assistant Professor,

Department of Psychiatry,

Weill Medical College,

Cornell University, New York;

Assistant Attending Psychiatrist,

Memorial Sloan-Kettering Cancer CenterNew York, New York

Assistant Professor of Psychiatry,

Harvard Medical School, Boston;

Researcher at Judge Baker Children’s CenterBoston, Massachusetts

Myron F Weiner MD

Investigator and Assistant Professor,

Department of Behavioral and Mental Health Research,

Joslin Diabetes Center and Harvard Medical School

Boston, Massachusetts

Elizabeth A Whitmore PhD

Assistant Professor,

Department of Psychiatry,

Division of Substance Dependence,

University of Colorado School of Medicine

Denver, Colorado

Rena R Wing PhD

Professor,

Department of Psychiatry and Human Behavior,

Brown University School of Medicine

Providence, Rhode Island

Departments of Psychiatry and Internal Medicine, University of Colorado Health Sciences CenterDenver, Colorado

Harvard Medical School;

Senior Clinical Social Worker,

Joslin Diabetes Center

Boston, Massachusetts

XIII

To our parents

whose support and encouragement

has meant so much to us

throughout our lives

XIV

Preface to First Edition

Psychiatric Secrets presents an up-to-date approach to the assessment and treatment

of psychiatric disorders in children, adults, and the elderly It uses a question and

answer format to address key principles in clinical practice in keeping with the concept

of The Secrets Series® The questions raise central issues and provide the

organizational structure for each chapter This process of question and answer yields a dialogue through which the expert clinicians who authored each chapter can provide their best “pearls of wisdom” often gained from years of experience as researchers, educators, and practicing clinicians

Psychiatric Secrets is divided into twelve sections that address in systematic fashion the

steps in the treatment process The book has a heavy emphasis on diagnosis, for it is the belief of the editors that careful, thoughtful diagnosis is the “springboard” to

treatment The first two sections outline a general approach to gathering and presenting clinical information The next three sections on major psychiatric syndromes and clinical problems focus primarily on issues related to diagnosis, including careful descriptions of common clinical characteristics, etiology, course of illness, and, when appropriate, basic features of treatment The section devoted to therapeutic approaches presents

introductions to both psychotherapeutic and biologic treatments, and includes

indications, contraindications, and side effects of interventions The final section

provides integrating information related to common problems and settings, such as child psychiatry, assessment and treatment of suicidal and violent patients, and

consultation-liaison psychiatry, as well as ethical and legal aspects of psychiatry

This text is intended to reinforce concepts for the mental health professional, yet is geared primarily for the medical student, house officer, and general practitioner The chapters are designed to be read independently, and thus there is occasional overlap of information Each author was given complete freedom to utilize his or her expertise in

expressing views about assessment or treatment Thus, Psychiatric Secrets presents

both basic information as well as the approach of experienced practitioners to specific topics

We are grateful to the authors for contributing their knowledge, time, and talent In addition, we would like to thank Linda Belfus and Polly E Parsons, who encouraged us

to undertake this project, and the many unsung heroes who typed, re-typed, re-re-typed, critiqued, proofread, and helped us move the book to completion Without all of their efforts, this book would not have happened.

James L Jacobson M.D.

Alan M Jacobson M.D.

XV

Preface to Second Edition

Psychiatric Secrets presents an up-to-date approach to the assessment and treatment

of psychiatric disorders in children, adults, and the elderly It uses a question and

answer format to address key principles in clinical practice in keeping with the concept

of The Secrets Series® The questions raise central issues and provide the

organizational structure for each chapter This process of question and answer yields a dialogue through which the expert clinicians who authored each chapter can provide their best “pearls of wisdom,” gained from years of experience as researchers,

educators, and practicing clinicians

This second edition of Psychiatric Secrets follows the same general outline and format

as the first edition It is divided into twelve sections that address in systematic fashion the steps in the treatment process The book heavily emphasizes diagnosis, for it is the belief of the Editors that careful, thoughtful diagnosis is the “springboard” to treatment The first two sections outline a general approach to gathering and presenting clinical information The next three sections on major psychiatric syndromes and clinical

problems focus primarily on issues related to diagnosis These sections include careful descriptions of common clinical care characteristics, etiology, course of illness, and basic features of treatment The section devoted to therapeutic approaches presents introductions to both psychotherapeutic and biologic treatments, and includes

indications, contraindications, and side effects of interventions The final sections

provide integrating information related to common problems and settings as well as developmental stages of life The sections include topics such as child psychiatry, assessment and treatment of suicidal and violent patients, and consultation-liaison psychiatry, as well as ethical and legal aspects of psychiatry

While the format of the second edition remains largely unchanged, the material in each

of the chapters has been updated to take advantage of developments in psychiatry In particular, those chapters devoted to psychopharmacology have been revised to reflect the rapid advances in treatment Because of the increasing complexity of the

pharmacology of psychiatric disorders, we have added one new chapter that addresses the complex drug interactions now involved in treating patients, especially those with both psychiatric and medical problems

This text is intended to reinforce concepts for the mental health professional, yet is geared primarily for the medical student, house officer, and general practitioner The chapters are designed to be read independently; consequently, there is occasional overlap of information Each author was given complete freedom to utilize his or her

expertise in expressing views about assessment and treatment Thus, Psychiatric

Secrets, 2nd edition presents both basic information as well as the approach of

experienced practitioners to specific topics

We are grateful to the authors for contributing their knowledge, time, and talent In

addition we would like to thank Linda Belfus and Polly E Parsons, who encouraged us

to undertake the project in the beginning, and Madeleine Jacobson, for her unflagging support through each of our two editions Moreover, Jacqueline Mahon has played a critical role as our editor for the second edition, and Nora Hallinan has “bird-dogged” this project from beginning to end Without all of these efforts, this book would not have happened

Finally, this book has been a special pleasure for the co-editors because it has allowed

us to mix the fun and pleasure of our work with that of our brotherly love It is not an exaggeration to say that the last several years have been a true labor of love

James L Jacobson M.D.

Alan M Jacobson M.D.

Section One - APPROACH TO CLINICAL

INTERVIEWING AND DIAGNOSIS

1

Chapter 1 - THE INITIAL PSYCHIATRIC INTERVIEW

Robert Waldinger M.D.

Alan M Jacobson M.D.

1 What are the primary aims of the first psychiatric interview?

To make an initial differential diagnosis and to formulate a treatment plan These goals are achieved by:

• Gathering information

Chief complaint History of current and past suicidal and homicidal

ideation History of presenting

Affective Family psychiatric and social history

Substance use and abuse

Changes in role and social

functioning

• Arriving at an empathic understanding of how the patient feels This understanding

is a critical base for establishing rapport with the patient When the clinician listens carefully and then communicates an appreciation of the patient’s worries and

concerns, the patient gains a sense of being understood This sense of being

understood is the bedrock of all subsequent treatment, and allows the clinician to initiate a relationship in which an alliance for treatment can be established

2 That’s a lot to focus on in the first meeting What about helping the patient?

The initial diagnosis and treatment plan may be rudimentary Indeed, when patients present in a crisis, the history may be confused, incomplete, or narrowly focused As a result, some interventions are started even when basic information about history, family relationships, and ongoing stressors is being gathered It is critical to remember that emotional difficulties often are isolating The experience of sharing one’s problem with a concerned listener can be enormously relieving in and of itself Thus, the initial interview

is the start of treatment even before a formal treatment plan has been established

3 How should the initial interview be organized?

There is no single ideal, but it is useful to think of the initial interview as having three components:

Establish initial rapport with the patient, and ask about the presenting complaint or

problems, i.e., what has brought the patient to the first meeting Some patients tell their stories without much guidance from the interviewer, whereas others require explicit instructions in the form of specific questions to help them organize their thoughts

During this phase of the first interview, the patient should be allowed to follow his or her own thought patterns as much as possible

Elicit specific information, including a history of the presenting problems, pertinent

medical information, family background, social history, and specific symptom and

behavioral patterns Formally test mental status (see Chapter 2 )

2

Ask if the patient has any questions or unmentioned concerns Initial

recommendations are then made to the patient for further evaluation and/or beginning treatment

Although the three parts of the interview can be considered separately, they often

weave together, e.g., mental status observations can be made from the moment the clinician meets the patient Pertinent medical and family history may be brought up in the course of presenting other concerns, and patients may pose important questions about treatment recommendations as they present their initial history

4 Is the initial assessment different for complex situations?

The initial psychiatric assessment may require more than one session for complex situations—for example, when evaluating children or families, or when assessing a patient’s suitability for a particular therapeutic approach, such as brief psychotherapy The initial assessment also may require information gathering from other sources: parents, children, spouse, best friend, teacher, police officers, and/or other healthcare providers These contacts may be incorporated into the first visit, or may occur later The first step in making such arrangements is to explain the reason for them to the patient and to obtain explicit, written permission for the contact

5 How should a referral source be approached?

It is almost always appropriate to call the referral source to gather information and to explain the initial diagnostic impressions and treatment plans Exceptions may occur when the referral comes from other patients, friends, or other nonprofessionals, whom the patient wishes to exclude from treatment

6 Are there any variations on these guidelines for an initial assessment?

Specific theoretical orientations may dictate important variations in the initial

assessment For example, a behavioral therapist guides discussion to specific analyses

of current problems and spends little time on early childhood experiences The

psychopharmacologic evaluation emphasizes specific symptom patterns, responses to prior medication treatment, and family history of psychiatric illness The approach

presented in this chapter is a broadly applicable set of principles that can be used in evaluating most patients

7 How is information gathered from an interview?

The interviewer must discover as much as possible about how the patient thinks and feels During the clinical interview, information is gathered from what the patient tells the interviewer; critically important clues also come from how the history unfolds Thus, both

the content of the interview (i.e., what the patient says) and the process of the

interview (i.e., how the patient says it) offer important routes to understanding the

patient’s problems Consider the order of information, the degree of comfort in talking about it, the emotions associated with the discussion, the patient’s reactions to

questions and initial comments, the coherence of the presentation, and the timing of the information The full elaboration of such information may take one or several sessions over the course of days, weeks, or months, but in the first interview hints of deeper

concerns may be suggested.

For example, a 35-year-old woman presented with worries about her son’s recurrent asthma and associated difficulties in school She talked freely about her worries and sought advice on how to help her son When asked about her husband’s thoughts, she became momentarily quiet She then said that he shared her concern and switched the discussion back to her son Her hesitancy hinted at other problems, which were left unaddressed in the initial session Indeed, she began the next session by asking, “Can I talk about something else besides my son?” After being reassured, she described her husband’s chronic anger at their son for his “weakness.” His anger and her own feelings

in response became an important focus of subsequent treatment

8 How should the interview be started?

The here and now is the place to begin all interviews Any one of a number of simple questions can be used: “What brings you to see me today? Can you tell me what has been troubling you? How

3

is it that you decided to make this appointment?” For anxious patients, structure is useful: early inquiry about age, marital status, and living situation may give them time to become comfortable before embarking on a description of their problems If the anxiety

is evident, a simple comment about the anxiety may help patients to talk about their worries

9 Is a highly structured format important?

No Patients must be given some opportunity to organize their information in the way that they feel most comfortable The interviewer who prematurely subjects the patient to

a stream of specific questions limits information about the patient’s own thinking

process, does not learn how the patient handles silences or sadness, and closes off the patient’s opportunities to hint at or introduce new topics Furthermore, the task of

formulating one specific question after another may intrude on the clinician’s ability to listen and to understand the patient

This does not mean that specific questions should be avoided Often, patients provide elaborate answers to specific questions such as “When were you married?” Their

responses may open new avenues to the inquiry The key is to avoid a rapid-fire

approach and to allow patients to elaborate their thoughts

10 How should questions be asked?

Questions should be phrased in a way that invites patients to talk Open-ended

questions that do not indicate an answer tend to allow people to elaborate more than