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Differential Diagnosis and Treatment of Headaches

Key Points Incidence/Epidemiology While headaches are extremely common and usually benign, there are many dangerous causes of headache. Headaches, even when benign, can be disabling. Pathophysiology The pathophysiology of a headache depends on its underlying cause. Clinical Findings Certain headache “red flags” may alert the clinician to dangerous causes of secondary headache. Differential Diagnosis Primary headaches, such as migraines, may be differentiated from secondary headaches; a…

Psychiatric Manifestations and Treatment of Seizure Disorders

Key Points Epilepsy is defined as two or more unprovoked seizures. Characterization of seizures and epilepsy syndromes is crucial in determining management and prognosis. Epilepsy may be caused by acquired brain damage or by genetic predisposition. Basic investigation of a seizure disorder includes physical examination, an electroencephalogram (EEG), and a magnetic resonance imaging (MRI) scan. Patients with epilepsy are at risk for multiple psychiatric co-morbidities, including…

Clinical Neurophysiology and Electroencephalography

Key Points The electroencephalogram (EEG) records cerebral electrical activity transmitted through the scalp, offering excellent temporal, but poor spatial, resolution. The EEG is used to detect epileptic activity, as well as focal and generalized cerebral dysfunction. The EEG is a helpful tool in clinical psychiatry, particularly to rule out non-convulsive seizures, and look for evidence of cerebral dysfunction. Evoked potentials can be used to test the…

Neuroimaging in Psychiatry

Key Points When structural neuroimaging is clinically indicated, magnetic resonance imaging (MRI) is usually the modality of choice. Computed tomography (CT) is typically recommended instead of MRI if an acute bleed is suspected. Guidelines for obtaining structural neuroimaging studies in patients with neuropsychiatric symptoms include patients with acute changes in mental status (including changes in affect, behavior, or personality) plus one of the following criteria: age…

Neuropsychiatric Principles and Differential Diagnosis

Key Points Background Behavioral Neurology and Neuropsychiatry is a medical specialty that cares for patients with problems that cross traditional boundaries between neurology and psychiatry. Neuropsychiatric symptoms and cognitive deficits can be correlated with altered function in anatomical regions and in cerebral networks. A firm understanding of the main cerebral structures and networks that mediate emotions, behavior, and cognition is the foundation of a useful neuropsychiatric…

The Neurological Examination

Key Points Cognitive impairment, behavioral changes, and psychiatric symptoms occur frequently in association with neurological conditions. A well-performed mental status and neurological examination are essential for the identification of medical and neurological conditions that impact cognition, behavior, and mood. The objective of the neurological examination is to verify the integrity of the central and peripheral nervous systems and to achieve neuroanatomical localization of signs and symptoms.…

Neuroanatomical Systems Relevant to Neuropsychiatric Disorders

Key Points The limbic system is composed of brain regions that participate in the comprehension of emotional meaning and the generation of emotional responses. The prefrontal cortex (PFC) receives and processes sensory, affective, and visceral information for the purpose of flexibly generating decisions, interpretations, social interactions, and other complex cognitions and behaviors, many of which are unique to human thought processes. Massive cortical input to the…

Geriatric Psychiatry

Key Points Depression in the elderly carries a very high risk of suicide. Symptoms of alcoholism and substance abuse are often confused with those of medical illness. The differential diagnosis of dementia is broad and the behavior problems challenging to treat. Delirium increases the prevalence and severity of disability, the length of hospital stay, and rates of morbidity and mortality. Caregivers of the elderly are at…

Psychiatric and Substance Use Disorders in Transitioning Adolescents and Young Adults

Key Points Background The term transitioning adolescents and young adults (TAY) (aged 16–26 years) has been coined to categorize this development stage, which has received increased attention. Parents of TAY sustain high burdens of care, particularly for those with common unmet needs. While psychopathology and substance abuse are the leading causes of disability worldwide, they constitute 45% of the disease burden in this age range. History…

Child and Adolescent Psychiatric Disorders

Key Points Psychopathology often begins and manifests, sometimes differently than in adults, in childhood and adolescence. Assessment of children and adolescents requires developmentally-sensitive adjustments to diagnostic criteria. Co-morbidities and symptoms from other disorders require consideration and sometimes targeted treatment interventions. Despite the resilience of children and adolescents, treatments are necessary and appropriate to minimize the effects of psychopathology on the child's development. Treatment planning for children…

Managed Care and Psychiatry

Key Points The finance of mental health care in the US has evolved from primarily a state-run asylum system to a mix of inpatient and outpatient care that is paid for by public and private funds. The US system of mental health care delivery is financed by a variety of public and private sources (including Medicare, Medicaid, state and local funds, and private insurance). Rising costs…

Community Psychiatry

Key Points Background The four principles of community mental health are population responsibility, prevention, community-based care with citizen involvement, and continuity of care. History Community psychiatry, the “third psychiatric revolution,” has an undulant history of reform and neglect. From the military experience of World War II came three central tenets of community psychiatry: immediacy, proximity, and expectancy. The seamless, inclusive care system envisioned in the 1960s…

Culture and Psychiatry

Key Points Background Cultural differences in the presentation of psychiatric illnesses exist and include most if not all psychiatric disorders, including depression and psychosis. Cultural aspects can play a fundamental role in the manifestation of symptoms and the appearance of syndromes that are culture specific. Gender, race, ethnicity, and culture may all have a tremendous impact on the diagnosis, treatment, and outcome for many individuals with…

Aggression and Violence

Key Points Background The etiology of violence is multi-factorial: it has biological, environmental, and psychosocial components. The best predictor of violence in a patient is prior acts of violence. History The initial psychiatric evaluation for all patients should include an assessment of current homicidal or aggressive thoughts as well as an assessment of past aggressive thoughts and behaviors. Assessment for risk factors includes a thorough history…

Serious Mental Illness

Key Points Five percent of adults in the US suffer from a serious mental illness (SMI), which is defined as a psychiatric illness that persists and is accompanied by functional disability. Modern, patient-centered treatment occurs in recovery-oriented community settings and includes peer support, family involvement, and chronic disease self-management. The treatment goal for SMI is not a cure but achieving the lowest symptom burden with the…

Genetics and Psychiatry

Key Points Background Most psychiatric disorders have a genetic component. The etiology of psychiatric disorders reflects a combination of genetic vulnerability and environmental factors Many psychiatric disorders can be familial and heritable due to the inheritance of genetic variations. Alternatively, psychiatric disorders can arise from de novo genetic mutations, mutations that are found in the offspring but not the parents or recent ancestry. Psychiatric disorders are…

Statistics in Psychiatric Research

Key Points Three classes of statistics are used commonly in psychiatric research: psychometric statistics assessing the reliability and validity of diagnostic interviews or rating scales ; descriptive statistics used to describe a group of subjects on these clinical variables and demographic variables; and inferential statistics used to make probabilistic statements about the effects of treatments or other variables on groups of subjects . The more statistical…

Psychiatric Epidemiology

Key Points Epidemiology is the study of the distribution and determinants of disease frequency in humans to inform the natural history, service needs, and etiology of illness. The frequency of disease can be expressed in different concepts, including cumulative incidence, incidence density, point prevalence, lifetime prevalence, and so on. Epidemiological studies frequently rely on assessment instruments to evaluate psychiatric disorders. It is important to first establish…

Psychiatric and Ethical Aspects of Care at the End of Life

Key Points Psychiatrists face multiple challenges when caring for a dying patient, encompassing issues of diagnosis and treatment, as well as larger ethical and legal considerations. Psychiatrists may be uniquely effective in helping a dying patient by ensuring optimization of palliative care and by assisting the patient and his or her family in the dying process. Psychiatric issues (such as depression, anxiety, delirium, substance dependence, and…

Approaches to Collaborative Care and Primary Care Psychiatry

Key Points Background Changes in psychiatry and the US health care system mandate the development of innovative models to provide high-quality, cost-effective, and efficient psychiatric care in the general medical setting. History Patients generally prefer to receive treatment for their psychiatric problems in the general medical setting, but patient, provider, and system factors interfere with appropriate recognition and treatment. Clinical and Research Challenges Psychiatric symptoms are…