Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

Patients With Disordered Sleep

Overview Scholars have long sought the cause and nature of sleep and sleep disorders, yet theories have far exceeded clear facts. Plato, for example, believed that sleep was caused by vapors arising from the stomach and condensing in the head, and Hippocrates believed that sleep was the result of blood and its warmth retreating into the body. Both 16th- and 17th-century scholars debated whether sleep was…

Catatonia, Neuroleptic Malignant Syndrome, and Serotonin Syndrome

Overview Each of the syndromes described in this chapter involves a complex interaction of motor, behavioral, and systemic manifestations that are derived from mechanisms that are not fully clear. What is clear is that neurotransmitters, such as dopamine (DA), gamma-aminobutyric acid (GABA), and glutamate, are of major importance in catatonia and neuroleptic malignant syndrome (NMS), whereas serotonin (5-hydroxytryptamine, 5-HT) is centrally involved in serotonin syndrome (SS).…

Patients With Infectious or Inflammatory Neuropsychiatric Impairment

Overview While there has always been a close association between neurologic and psychiatric disorders, in the past decade, with the identification of a new class of autoimmune encephalitides that are associated with profound neuropsychiatric impairments, and the realization that psychiatric disorders, such as schizophrenia, may be linked with deficient components of the immune system that are responsible for synaptic pruning, the lines between the two disciplines…

Patients With Abnormal Movements

Overview Psychiatrists encounter patients with abnormal movements in various clinical settings. Recognizing and correctly labeling motor phenomena in each setting helps to create a differential diagnosis that serves as the basis for optimal treatment, since abnormal movements can be the first indication of an unsuspected medical or neurologic disorder in a psychiatric patient treated for psychiatric symptoms. A solid understanding of prototypical movement disorders (e.g., Huntington's…

Patients With Cerebrovascular Disease and Traumatic Brain Injury

The structure and function of the central nervous system (CNS) is altered by many neurologic disorders. Because the CNS controls affect, behavior, and cognition, neurologic disorders may lead to neuropsychiatric symptoms that resemble those found in primary psychiatric conditions. Therefore, the general hospital psychiatrist is frequently called on to assess patients who have classic psychiatric symptoms caused by an underlying neurologic disease. In this chapter, we…

Patients With Seizure Disorders

Overview The structure and function of the central nervous system (CNS) is altered by many neurologic disorders. Because the CNS controls affect, behavior, and cognition, neurologic disorders can lead to neuropsychiatric symptoms that resemble those found in primary psychiatric conditions. Therefore, the general hospital psychiatrist is frequently called on to assess patients who have classic psychiatric symptoms caused by an underlying neurologic condition (e.g., a seizure…

Pain Patients

Overview Of all human experience, pain is, as long as it lasts, the most absorbing; it is the only human experience that when it comes to an end, automatically confers a sense of relief and joy. Moreover, by its very nature it is solitary. Despite its intensity and its unequalled power over mind and body, pain can be difficult to recall once it subsides. The International…

Patients With an Eating Disorder

Overview Eating disorders are serious psychiatric illnesses, with high rates of morbidity and mortality. They are most common in young women, but affect people of all ages, genders, races, ethnicities, and socioeconomic statuses. Individuals with eating disorders can develop serious medical complications, requiring multidisciplinary treatment. Given these risks, early detection and treatment of an eating disorder can increase the likelihood of recovery. Medical stabilization is key…

Psychosomatic Conditions: Somatic Symptom and Related Disorders, Functional Somatic Syndromes, and Deception Syndromes

Overview The 2003 approval by the American Board of Medical Specialties of “Psychosomatic Medicine” as a certified subspecialty of psychiatry evokes the obvious question of what this name means. Despite high-minded ideas about its referring to clinical and scientific attention to holistic approaches to health and disease, or to a bridge between psychiatry and the rest of medicine, for most medical professionals and many members of…

Patients With Substance Use Disorders

Overview Without a doubt, substance use disorders (SUDs) present one of the gravest difficulties currently facing the United States healthcare system. Over the past two decades, the number of patients treated for substance use-related problems in the United States has grown steadily, and over the past 5 years it has reached epidemic proportions. Data from the Centers for Disease Control and Prevention (CDC) indicate that in…

Patients With Alcohol Use Disorder

Overview Alcohol remains one of the most prevalent and clinically relevant drugs of abuse, with an estimated 75 million people worldwide meeting criteria for an alcohol use disorder (AUD) in 2004. In the United States, two-thirds of all adults consume alcoholic beverages; an estimated 8 million Americans meet criteria for a severe AUD. Furthermore, approximately 500,000 individuals each year experience acute alcohol withdrawal severe enough to…

Anxious Patients

Overview Clinical challenges in the diagnosis and treatment of anxiety are abundant in the general hospital setting: discerning normal from pathologic anxiety, differentiating medical from psychiatric causes, and choosing effective therapeutic approaches. In addition to a knowledge of medical and psychiatric differential diagnoses, the clinician may rely on a variety of strategies and interventions that involve pharmacologic, cognitive-behavioral, interpersonal, and psychodynamic skills. The ubiquity of anxiety…

Psychotic Patients

Psychosis , broadly defined, is a gross impairment of reality testing. Psychosis can result from a wide range of psychiatric and medical disturbances and may take several forms. The elderly woman, who lies quietly in bed listening to Satan whisper, bears little resemblance to the wildly agitated young man who accuses the nursing staff of trying to poison him. Hallucinations and delusions are the two classic…

Patients With Neurocognitive Disorders

As life expectancy extends and the baby boomer generation begins to reach geriatric age, we will confront an epidemic of neurocognitive disorders (NCDs) in general hospitals. The number of cases of Alzheimer's disease (AD), the most common cause of NCD, is expected to quadruple in the coming decades. Unfortunately, most NCDs (used interchangeably in this chapter with the term “dementia”), including AD, are incurable, but progression…

Delirious Patients

Delirium has probably replaced syphilis as “the great imitator” because its varied presentations have led to misdiagnoses among almost every major category of mental illness. Delirium is a syndrome caused by an underlying physiologic disturbance and marked by a fluctuating course of impairments in consciousness, attention, and perception. Thus, delirium is often mistaken for: depression, when the patient has a withdrawn or flat affect; mania, when…

Depressed Patients

Overview A major depressive disorder (MDD) serious enough to warrant professional care affects approximately 16% of the general population during their life-time. Both the Epidemiological Catchment Area (ECA) study and the National Comorbidity Survey study have found that MDD is prevalent, with cross-sectional rates of up to 6.6%. Although this condition ranks first among reasons for psychiatric hospitalization (23.3% of total hospitalizations), it has been estimated…

Diagnostic Rating Scales and Laboratory Tests

Although the interview and the mental status examination compose the primary diagnostic tools in psychiatry, the use of standardized rating scales and laboratory tests provides important adjunctive data. In addition to ruling out medical and neurologic explanations for psychiatric symptoms, the quantitative instruments described in this chapter play important clinical roles in clarifying disease severity, identifying patients who meet sub-syndromal criteria within a particular diagnosis, assessing…

Psychological and Neuropsychological Assessment

Overview Psychological and neuropsychological assessments can be invaluable in cases where there is a question regarding differential diagnosis, a change in functioning from a premorbid baseline, or when a baseline is needed to assess the efficacy of planned treatments. Clinical psychologists who have doctoral and postdoctoral training in assessment perform these types of evaluations, generally working in a consultative role. Psychological evaluations focus on distinguishing between…

Limbic Music: The Band Plays On

Introduction First appearing in 1987 in an internally published collection of essays celebrating the 50th anniversary of the Massachusetts General Hospital Department of Psychiatry, George Murray's “Limbic Music” is a rare example of the medical literature producing actual literature . Its synthesis of neuroscience, philosophy, clinical wisdom, and engaging writing was, like Dr. Murray himself, unique. Subsequent versions of that essay in the journal Psychsomatics ,…

Functional Neuroanatomy and the Neurologic Examination

For the psychiatric consultant, the neurologic examination is an important component of every patient evaluation. By reviewing the main components of the standard examination and attempting to relate them to anatomic constructs, the consulting psychiatrist may gain a theoretical and pragmatic framework for the neurologic examination that can facilitate case formulation, differential diagnosis, and treatment planning. Functional Neuroanatomy At its most basic level, the nervous system…