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Antipsychotic Drugs

Key Points All antipsychotics share dopamine 2 blockade as the presumed main mechanism of action. Primary symptom targets of antipsychotics are positive symptoms (disorganization, delusions, and hallucinations) and agitation; their efficacy for negative symptoms and cognitive deficits of schizophrenia is questionable. Increasingly, antipsychotics are used for treatment of mood disorders. Historically, antipsychotics have been grouped into first-generation antipsychotics (typical or conventional antipsychotics, which are all characterized…

The Pharmacotherapy of Anxiety Disorders

Key Points A variety of pharmacological agents are effective for the treatment of anxiety disorders. The SSRIs and SNRIs are first-line pharmacological agents for the treatment of anxiety disorders. Benzodiazepines are effective, rapidly acting and well-tolerated, but are associated with the risk of abuse and dependence, and lack efficacy for co-morbid depression. Anticonvulsants, atypical antipsychotics, adrenergic antagonists, and other agents also play role in the treatment…

Psychiatric Neuroscience: Incorporating Pathophysiology into Clinical Case Formulation

Key Points One can approach the study of the brain and its pathophysiology from various perspectives with different levels of resolution: molecular, genetic, cellular, synaptic, systems, and behavioral. Pathological processes and therapeutic interventions can target one or more of these levels, leading to a cascade of events that changes each of them. Affect, behavior, and cognition are processed in specific brain circuits, and their altered function…

Personality and Personality Disorders

Key Points Epidemiology Personality has evolved to guide both social and interpersonal function. Use of dimensional diagnostic systems improves reliability and descriptive breadth. Clinical Findings Normal personality traits and DSM-5 personality disorders share many features. Treatment Options Empirical findings indicate that personality disorders respond positively to a wide range of psychotherapies. Targeted pharmacotherapy for personality disorders can be implemented in a rational fashion. Overview The last…

Grief, Bereavement, and Adjustment Disorders

Key Points Epidemiology Death and loss are part of the human condition; therefore, everyone is at risk for the experience of grief. Clinical Findings Grief may be defined as the physical and emotional pain precipitated by a significant loss. Though the course of adjustment disorders is usually brief, the symptoms can be quite severe and may include suicidal ideation; when compared to patients with major depression,…

Eating Disorders: Evaluation and Management

Key Points Incidence Eating disorders are prevalent among young women, but they can occur across diverse ages and populations. Epidemiology Eating disorders are associated with serious medical co-morbidity related to nutritional compromise, to low weight, and to chronic bingeing and purging behaviors. Treatment Options The majority of individuals with an eating disorder do not access treatment for this illness. Leading evidence-based treatments include cognitive-behavioral therapy for…

Sexual Disorders and Sexual Dysfunction

Key Points Incidence Sexual disorders are common, occurring in 43% of women and 31% of men in the US. Epidemiology Advanced age and co-morbid medical (particularly cardiovascular) and psychiatric conditions are associated with higher rates of sexual dysfunction in both genders. Paraphilic disorders are associated with attention-deficit/hyperactivity disorder (ADHD). Pathophysiology Sexual function depends on a complex interplay of biological, social, cultural, and psychological factors, many of…

Dissociative Disorders

Key Points Epidemiology A large segment of the general population will endorse dissociative symptoms in the absence of significant psychopathology, suggesting that these symptoms exist along a spectrum from normal to pathological. Dissociative disorders are most often associated with a history of trauma. Clinical Findings Dissociative disorders are a heterogeneous set of psychiatric conditions that are characterized by the lack of a fully integrated consciousness. Although…

Trauma and Posttraumatic Stress Disorder

Key Points Incidence/Epidemiology Exposure to events capable of causing posttraumatic stress disorder (PTSD) is the rule rather than the exception. Life-time incidence of exposure to events causing PTSD is greater than 50%. However, development of PTSD following a traumatic event is the exception rather than the rule. The overall probability of developing PTSD following a traumatic event is less than 10%. However, assaults and other traumatic…

Obsessive-compulsive Disorder and Obsessive-compulsive and Related Disorders

Key Points Obsessive-compulsive disorder (OCD) and obsessive-compulsive-related disorders (OCRDs) now comprise an independent disease category within the DSM-5, as OCD is no longer classified as an anxiety disorder. OCRDs include hoarding disorder (HD), and three body-focused disorders: body dysmorphic disorder (BDD), trichotillomania (hair-pulling disorder) (TTM) and skin-picking (excoriation) disorder (SPD). Incidence OCD and OCRDs are common yet under-recognized, with individual prevalence rates in the range of…

Anxiety Disorders

Key Points Incidence Anxiety disorders are the most prevalent mental health problem in the US, and are associated with marked distress and functional impairments in multiple domains. Epidemiology/Pathophysiology The pathogenesis of anxiety disorders likely resides in the interaction of innate biological vulnerabilities and specific environmental events or stressors. Clinical Findings/Differential Diagnoses Routine screening for anxiety disorders in medical settings is essential; people with anxiety disorders frequently…

Psychiatric Illness during Pregnancy and the Post-partum Period

Key Points Epidemiology Pregnancy does not protect against psychiatric disorders. Clinical Findings A growing amount of information exists regarding the course of psychiatric illness during pregnancy and the reproductive safety of psychotropic medications. Complications With the exception of one anticonvulsant, sodium valproate, the majority of psychotropics are NOT major teratogens. Post-partum depression is the most common complication in modern obstetrics and definitive treatment is essential to…

Bipolar Disorder

Key Points Incidence The lifetime prevalence of bipolar disorders is approximately 2%. Epidemiology Bipolar disorder is associated with significant morbidity, including functional impairment, as well as significant risk for suicide. Clinical Findings Diagnosis of bipolar disorder rests on establishing current or prior manic, hypomanic, mixed, or depressive episodes. Treatment Options Treatments with evidence of efficacy for prevention of recurrence of mood episodes in bipolar disorder include…

Mood Disorders: Depressive Disorders (Major Depressive Disorder)

Key Points Incidence The annual incidence of major depressive disorder (MDD) is approximately 3%, and the average duration of an episode of MDD is 30 weeks. Epidemiology MDD is a prevalent disorder, with a global point prevalence of approximately 5%. The life-time prevalence rates of MDD in the US and Western European countries are in the range of 10%–20% in the general population. Pathophysiology The pathophysiology…

Psychosis and Schizophrenia

Key Points Schizophrenia is a clinical diagnosis that is based on a combination of characteristic symptoms of sufficient severity (in the absence of other factors that would account for them) that typically begins in adolescence or early adulthood. Even if it is successfully treated, function often remains impaired; moreover, there is a high risk of recurrence of psychotic symptoms. In addition to psychosis, patients with schizophrenia…

Drug Addiction

Key Points Incidence Depending on the drug used and the clinical setting, up to 50% of patients in mental-health treatment will have a co-occurring substance-use disorder. Epidemiology Substance abuse is a major public health problem that affects a large number of psychiatric patients. Screening for substance use and abuse should be a routine part of all mental-health evaluations. The problem is particularly severe in public sector…

Alcohol-Related Disorders

Key Points Incidence Alcohol misuse is one of the leading causes of morbidity and mortality in the US. Epidemiology The highest rates of alcohol use, heavy binge use, and alcohol use disorders occur between the ages of 18 and 29 years. Pathophysiology Alcohol causes harm through three distinct, but related pathways: intoxication, toxicity, and alcohol use disorder. Clinical Findings Alcohol use disorders are heterogeneous disorders that…

Factitious Disorders and Malingering

Key Points Incidence Factitious disorder and malingering are uncommon syndromes that involve voluntary symptom production and deception of medical providers. Pathophysiology Factitious disorder involves the conscious production of symptoms with the primary motivation of assuming the sick role. Clinical findings Factitious disorder may manifest with predominantly physical symptoms, predominantly psychological symptoms, or a combination of the two. Factitious disorder imposed on another (previously referred to as…

Somatic Symptom Disorders

Key Points Incidence Medically-unexplained symptoms (MUS) are ubiquitous in inpatients and outpatients. Epidemiology Patients with MUS that suffer from somatoform disorders may represent the largest group with psychopathology within primary care populations (at 10%–24%). Pathophysiology While the etiology of somatic symptom disorder is poorly understood and insufficiently studied epidemiologically, limited data extrapolated from other conditions suggest that a combination of factors (e.g., physiology, personality, life experiences,…

Impulse-Control Disorders

Key Points Incidence and Epidemiology Impulsivity is common but diagnosed disorders range from rare to close to 10% of the population. Pathophysiology Disturbances in the reward system (dopamine) as well as in the serotonergic neurocircuitry help us understand these disorders. Other neurotransmitters are implicated, as well as genetic linkages and vulnerabilities. Clinical Findings The urge to behave in a dysfunctional manner in spite of consequences underlies…