First Aid For The Psychiatry Clerkship Fourth Edition Latha Ganti Full Chapter

First Aid for the Psychiatry Clerkship,
Fourth Edition Latha Ganti

Visit to download the full and correct content document:
https://ebookmass.com/product/first-aid-for-the-psychiatry-clerkship-fourth-edition-lath
a-ganti/
FOCUSED LEARNING for the
psychiatry clerkship
Tips on what to know to IMPRESS

ATTENDINGS and EARN HONORS
on the shelf exam
Completely UPDATED
FOR THE DSM-5
FIRST AID FOR
THE®
PSYCHIATRY
CLERKSHIP
FOURTH EDITION
LATHA GANTI, MD, MS, MBA, FACEP Sean M. Blitzstein, MD

Director, VACO Southeast Specialty Care Director, Psychiatry Clerkship
Center of Innovation Clinical Associate Professor of Psychiatry
Orlando VA Medical Center University of Illinois at Chicago
Professor of Emergency Medicine Chicago, Illinois
University of Central Florida
Orlando, Florida
MATTHEW S. KAUFMAN, MD
Associate Director
Department of Emergency Medicine
Richmond University Medical Center
New York, New York
New York / Chicago / San Francisco / Athens / Lisbon / London / Madrid / Mexico City
Milan / New Delhi / Singapore / Sydney / Toronto
Copyright © 2016 by McGraw-Hill Education. All rights reserved. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be
reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher.
ISBN: 978-0-07-184175-7
MHID: 0-07-184175-X
The material in this eBook also appears in the print version of this title: ISBN: 978-0-07-184174-0,
MHID: 0-07-184174-1.
eBook conversion by codeMantra

Version 1.0
All trademarks are trademarks of their respective owners. Rather than put a trademark symbol after every occurrence of a trademarked name, we use names in an editorial fashion
only, and to the benefit of the trademark owner, with no intention of infringement of the trademark. Where such designations appear in this book, they have been printed with
initial caps.
McGraw-Hill Education eBooks are available at special quantity discounts to use as premiums and sales promotions or for use in corporate training programs. To contact a
representative, please visit the Contact Us page at www.mhprofessional.com.
Previous editions copyright © 2011, 2005, 2002 by The McGraw-Hill Companies, Inc.
First Aid for the® is a registered trademark of McGraw-Hill Education. All rights reserved
Notice
Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required. The authors and the
publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted
at the time of publication. However, in view of the possibility of human error or changes in medical sciences, neither the authors nor the publisher nor any other party who has been
involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they disclaim all responsibility
for any errors or omissions or for the results obtained from use of the information contained in this work. Readers are encouraged to confirm the information contained herein with
other sources. For example and in particular, readers are advised to check the product information sheet included in the package of each drug they plan to administer to be certain
that the information contained in this work is accurate and that changes have not been made in the recommended dose or in the contraindications for administration. This recom-
mendation is of particular importance in connection with new or infrequently used drugs.
TERMS OF USE
This is a copyrighted work and McGraw-Hill Education and its licensors reserve all rights in and to the work. Use of this work is subject to these terms. Except as permitted under
the Copyright Act of 1976 and the right to store and retrieve one copy of the work, you may not decompile, disassemble, reverse engineer, reproduce, modify, create derivative
works based upon, transmit, distribute, disseminate, sell, publish or sublicense the work or any part of it without McGraw-Hill Education’s prior consent. You may use the work
for your own noncommercial and personal use; any other use of the work is strictly prohibited. Your right to use the work may be terminated if you fail to comply with these terms.
THE WORK IS PROVIDED “AS IS.” McGRAW-HILL EDUCATION AND ITS LICENSORS MAKE NO GUARANTEES OR WARRANTIES AS TO THE ACCURACY,
ADEQUACY OR COMPLETENESS OF OR RESULTS TO BE OBTAINED FROM USING THE WORK, INCLUDING ANY INFORMATION THAT CAN BE ACCESSED
THROUGH THE WORK VIA HYPERLINK OR OTHERWISE, AND EXPRESSLY DISCLAIM ANY WARRANTY, EXPRESS OR IMPLIED, INCLUDING BUT NOT
LIMITED TO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. McGraw-Hill Education and its licensors do not warrant
or guarantee that the functions contained in the work will meet your requirements or that its operation will be uninterrupted or error free. Neither McGraw-Hill Education nor
its licensors shall be liable to you or anyone else for any inaccuracy, error or omission, regardless of cause, in the work or for any damages resulting therefrom. McGraw-Hill
Education has no responsibility for the content of any information accessed through the work. Under no circumstances shall McGraw-Hill Education and/or its licensors be liable
for any indirect, incidental, special, punitive, consequential or similar damages that result from the use of or inability to use the work, even if any of them has been advised of the
possibility of such damages. This limitation of liability shall apply to any claim or cause whatsoever whether such claim or cause arises in contract, tort or otherwise.
CONTENTS
Contributing Authors v
Introduction vii
Chapter 1: How to Succeed in the Psychiatry Clerkship 1
Chapter 2: Examination and Diagnosis 11
Chapter 3: Psychotic Disorders 21
Chapter 4: Mood Disorders 33
Chapter 5: Anxiety, Obsessive-Compulsive, Trauma, and Stressor-Related Disorders 47
Chapter 6: Personality Disorders 63
Chapter 7: Substance-Related and Addictive Disorders 79
Chapter 8: Neurocognitive Disorders 97
Chapter 9: Geriatric Psychiatry 113
Chapter 10: Psychiatric Disorders in Children 121
Chapter 11: Dissociative Disorders 133
Chapter 12: Somatic Symptom and Factitious Disorders 139
Chapter 13: Impulse Control Disorders 145
Chapter 14: Eating Disorders 151
Chapter 15: Sleep-Wake Disorders 159
Chapter 16: Sexual Dysfunctions and Paraphilic Disorders 171
Chapter 17: Psychotherapies 179
Chapter 18: Psychopharmacology 189
Chapter 19: Forensic Psychiatry 209
Index 217
iii
CONTRIBUTING AUTHORS
Sean M. Blitzstein, MD Kelley A. Volpe, MD
Director, Psychiatry Clerkship Chief Resident, Department of Psychiatry
Clinical Associate Professor of Psychiatry University of Illinois at Chicago College of Medicine
University of Illinois at Chicago Chicago, Illinois
Chicago, Illinois Eating Disorders
Examination and Diagnosis Sleep-Wake Disorders
Personality Disorders Psychotherapies
Substance-Related and Addictive Disorders Forensic Psychiatry
Geriatric Psychiatry
Somatic Symptom and Factitious Disorders
Sexual Dysfunctions and Paraphilic Disorders Alexander Yuen, MD
Resident, Department of Psychiatry
University of Illinois at Chicago
Amber C. May, MD Chicago, Illinois
Resident, Department of Psychiatry Psychotic Disorders
University of Illinois at Chicago Mood Disorders
Chicago, Illinois Impulse Control Disorders
Anxiety, Obsessive-Compulsive, Trauma and Stressor-Related Disorders Psychopharmacology
Neurocognitive Disorders
Psychiatric Disorders in Children
Dissociative Disorders
v
INTRODUCTION
This clinical study aid was designed in the tradition of the First Aid series of
books. It is formatted in the same way as the other books in this series; how-
ever, a stronger clinical emphasis was placed on its content in relation to psy-
chiatry. You will find that rather than simply preparing you for success on the
clerkship exam, this resource will help guide you in the clinical diagnosis and
treatment of many problems seen by psychiatrists.
Each of the chapters in this book contains the major topics central to the
practice of psychiatry and has been specifically designed for the medical stu-
dent learning level. It contains information that psychiatry clerks are expected
to learn and will ultimately be responsible for on their shelf exams.
The content of the text is organized in the format similar to other texts in the
First Aid series. Topics are listed by bold headings, and the “meat” of the top-
ics provides essential information. The outside margins contain mnemonics,
diagrams, exam and ward tips, summary or warning statements, and other
memory aids. Exam tips are marked by the icon, tips for the wards by the
icon, and clinical scenarios by the icon.
vii
Chapter 1
How to Succeed in the

Psychiatry Clerkship
Why Spend Time on Psychiatry? 2 Keep Patient Information Handy 3
How to Behave on the Wards 2 Present Patient Information in an Organized Manner 3
Respect the Patients 2 How to Prepare for the Clerkship (Shelf ) Exam 4
Respect the Field of Psychiatry 2 Study with Friends 4
Take Responsibility for Your Patients 3 Study in a Bright Room 4
Respect Patients’ Rights 3 Eat Light, Balanced Meals 4
Volunteer 3 Take Practice Exams 4
Be a Team Player 3 Pocket Cards 5
1
2 Chapter 1 HOW TO SUCCEED IN THE PSYCHIATRY CLERKSHIP
The psychiatry clerkship will most likely be very interesting and exciting.
A key to doing well in this clerkship is finding the balance between drawing
a firm boundary of professionalism with your patients and creating a relation-
ship of trust and comfort.
Why Spend Time on Psychiatry?

For most, your medical school psychiatry clerkship will encompass the
entirety of your formal training in psychiatry during your career in medicine.
Being aware of and understanding the features of mental dysfunction in psy-

chiatric patients will serve you well in recognizing psychiatric symptoms in
your patients, regardless of your specialty choice.
While anxiety and depression can worsen the prognosis of patients’ other
medical conditions, medical illnesses can cause significant psychological
stress, often uncovering a previously subclinical psychiatric condition. The
stress of extended hospitalizations can strain normal mental and emotional
functioning beyond their adaptive reserve, resulting in transient psychiatric
symptoms.
Psychotropic medications are frequently prescribed in the general popula-

tion. Many of these drugs have significant medical side effects and drug
interactions. You will become familiar with these during your clerkship
and will encounter them in clinical practice regardless of your field of
medicine.
Because of the unique opportunity to spend a great deal of time interacting

with your patients, the psychiatry clerkship is an excellent time to practice
your interview skills and “bedside manner.”
How to Behave on the Wards
R E S P E C T T H E PAT I E N T S
Always maintain professionalism and show the patients respect. Be respectful

when discussing cases with your residents and attendings.
R E S P E C T T H E F I E L D O F P S Y C H I AT R Y
■■ Regardless of your interest in psychiatry, take the rotation seriously.

■■ You may not agree with all the decisions that your residents and attendings
make, but it is important for everyone to be on the same page. Be aware of
patients who try to split you from your team.
■■ Dress in a professional, conservative manner.
■■ Working with psychiatric patients can often be emotionally taxing. Keep
yourself healthy.
■■ Psychiatry is a multidisciplinary field. It would behoove you to continu-
ously communicate with nurses, social workers, and psychologists.
■■ Address patients formally unless otherwise told.
HOW TO SUCCEED IN THE PSYCHIATRY CLERKSHIP Chapter 1 3
TA K E R E S P O N S I B I L I T Y F O R Y O U R PAT I E N T S
Know as much as possible about your patients: their history, psychiatric and
medical problems, test results, treatment plan, and prognosis. Keep your
intern or resident informed of new developments that they might not be
aware of, and ask them for any updates you might not be aware of. Assist the
team in developing a plan; speak to consultants and family members. Never
deliver bad news to patients or family members without the assistance of your
supervising resident or attending.
R E S P E C T PAT I E N T S ’ R I G H T S
1. All patients have the right to have their personal medical information kept
private. This means do not discuss the patient’s information with family
members without that patient’s consent, and do not discuss any patient in
public areas (e.g., hallways, elevators, cafeterias).
2. All patients have the right to refuse treatment. This means they can refuse
treatment by a specific individual (the medical student) or of a specific
type (no electroconvulsive therapy). Patients can even refuse lifesaving
treatment. The only exceptions to this rule are if the patient is deemed
to not have the capacity to make decisions or if the patient is suicidal or
homicidal.
3. All patients should be informed of the right to seek advance directives on
admission. Often, this is done by the admissions staff or by a social worker.
If your patient is chronically ill or has a life-threatening illness, address
the subject of advance directives with the assistance of your resident or
attending.
VOLUNTEER
Be enthusiastic and self-motivated. Volunteer to help with a procedure or a

difficult task. Volunteer to give a 20-minute talk on a topic of your choice, to
take additional patients, and to stay late.
BE A TEAM PLAYER
Help other medical students with their tasks; teach them information you
have learned. Support your supervising intern or resident whenever possible.
Never steal the spotlight or make a fellow medical student look bad.
K E E P PAT I E N T I N F O R M AT I O N H A N D Y
Use a clipboard, notebook, or index cards to keep patient information, includ-

ing a history and physical, lab, and test results, at hand.
P R E S E N T PAT I E N T I N F O R M AT I O N I N A N O R G A N I Z E D M A N N E R
Here is a template for the “bullet” presentation:
“This is a [age]-year-old [gender] with a history of [major history such

as bipolar disorder] who presented on [date] with [major symptoms,
such as auditory hallucinations] and was found to have [working diag-
nosis]. [Tests done] showed [results]. Yesterday, the patient [state impor-
tant changes, new plan, new tests, new medications]. This morning the
patient feels [state the patient’s words], and the mental status and physi-
cal exams are significant for [state major findings]. Plan is [state plan].”
The newly admitted patient generally deserves a longer presentation following

the complete history and physical format.
Many patients have extensive histories. The complete history should be pres-
ent in the admission note, but during ward presentations, the entire history
is often too much to absorb. In these cases, it will be very important that you
generate a good summary that is concise but maintains an accurate picture of
the patient.
How to Prepare for the Clerkship (Shelf ) Exam

If you have studied the core psychiatric symptoms and illnesses, you will know
a great deal about psychiatry. To specifically study for the clerkship or shelf
exam, we recommend:
2–3 weeks before exam: Read this entire review book, taking notes.
10 days before exam: Read the notes you took during the rotation and the
corresponding review book sections.
5 days before exam: Read this entire review book, concentrating on lists and
mnemonics.
2 days before exam: Exercise, eat well, skim the book, and go to bed early.
1 day before exam: Exercise, eat well, review your notes and the mnemonics,
and go to bed on time. Do not have any caffeine after 2 pm.
Other helpful studying strategies include:
STUDY WITH FRIENDS
Group studying can be very helpful. Other people may point out areas that
you have not studied enough and may help you focus more effectively. If you
tend to get distracted by other people in the room, limit this amount to less
than half of your study time.
STUDY IN A BRIGHT ROOM
Find the room in your home or library that has the brightest light. This will
help prevent you from falling asleep. If you don’t have a bright light, obtain a
halogen desk lamp or a light that simulates sunlight.
E AT L I G H T, B A L A N C E D M E A L S
Make sure your meals are balanced, with lean protein, fruits and vegetables,
and fiber. A high-sugar, high-carbohydrate meal will give you an initial burst
of energy for 1–2 hours, but then your blood sugar will quickly drop.
TA K E P R A C T I C E E X A M S
The purpose of practice exams is not just for the content that is contained in
the questions, but the process of sitting for several hours and attempting to
choose the best answer for each and every question.
POCKET CARDS
The “cards” on the following page contain information that is often helpful in
psychiatry practice. We advise that you make a photocopy of these cards, cut
them out, and carry them in your coat pocket.
Mental Status Exam
Appearance/Behavior: apparent age, attitude and cooperativeness, eye

contact, posture, dress and hygiene, psychomotor status
Speech: rate, rhythm, volume, tone, articulation
Mood: patient’s subjective emotional state—depressed, anxious, sad,

angry, etc.
Affect: objective emotional expression—euthymic, dysphoric, euphoric,

appropriate (to stated mood), labile, full, constricted, flat, etc.
Thought process: logical/linear, circumstantial, tangential, flight of

ideas, looseness of association, thought blocking
Thought content: suicidal/homicidal ideation, delusions, preoccupa-

tions, hyperreligiosity
Perceptual disturbances: hallucinations, illusions, derealization, deper-

sonalization
Cognition:
Level of consciousness: alert, sleepy, lethargic
Orientation: person, place, date
Attention/concentration: serial 7s, spell “world” backwards
Memory:
Registration: immediate recall of three objects
Short term: recall of objects after 5 minutes
Long term: ask about verifiable personal information
Fund of knowledge: current events
Abstract thought: interpretation of proverbs, analogies
Insight: patient’s awareness of his/her illness and need for treatment
Judgment: patient’s ability to approach his/her problems in an appropri-

ate manner
Delirium
Characteristics: acute onset, waxing/waning sensorium (worse at night),

disorientation, inattention, impaired cognition, disorganized thinking,
altered sleep-wake cycle, perceptual disorders (hallucinations, illusions)
(continued)
Etiology: drugs (narcotics, benzodiazepines, anticholinergics, TCAs, ste-

roids, diphenhydramine, etc.), EtOH withdrawal, metabolic (cardiac,
respiratory, renal, hepatic, endocrine), infection, neurological causes
(increased ICP, encephalitis, postictal, stroke)
Investigations:
Routine: CBC, electrolytes, glucose, renal panel, LFTs, TFTs, UA,
urine toxicology, CXR, O2 sat, HIV
Medium-yield: ABG, ECG (silent MI), ionized Ca2+
If above inconclusive: Head CT/MRI, EEG, LP
Management: identify/correct underlying cause, simplify Rx regi-

men, d/c potentially offensive medications if possible, avoid benzo-
diazepines (except in EtOH withdrawal), create safe environment,
provide reassurance/education, judiciously use antipsychotics for acute
agitation
Mini-Mental State Examination (MMSE)
Orientation (10):
What is the [year] [season] [date] [day] [month]? (1 pt. each)

Where are we [state] [county] [town] [hospital] [floor]?
Registration (3): Ask the patient to repeat three unrelated objects (1 pt.
each on first attempt). If incomplete on first attempt, repeat up to six
times (record # of trials).
Attention (5): Either serial 7s or “world” backwards (1 pt. for each

correct letter or number).
Delayed recall (3): Ask patient to recall the three objects previously
named (1 pt. each).
Language (9):
■■ Name two common objects, e.g., watch, pen (1 pt. each).
■■ Repeat the following sentence: “No ifs, ands, or buts” (1 pt.).
■■ Give patient blank paper. “Take it in your right hand, use both hands
to fold it in half, and then put it on the floor” (1 pt. for each part
correctly executed).
■■ Have patient read and follow: “Close your eyes” (1 pt.).
■■ Ask patient to write a sentence. The sentence must contain a
subject and a verb; correct grammar and punctuation are not
necessary (1 pt.)
■■ Ask the patient to copy the design. Each figure must have five sides,
and two of the angles must intersect (1 pt.).
Mania (“DIG FAST”)
Distractibility
Irritable mood/insomnia
Grandiosity
Flight of ideas
Agitation/increase in goal-directed activity
Speedy thoughts/speech
Thoughtlessness: seek pleasure without regard to consequences
Suicide Risk (“SAD PERSONS”)

Sex—male
Age >60 years
Depression
Previous attempt
Ethanol/drug abuse
Rational thinking loss
Suicide in family
Organized plan/access
No support
Sickness
Depression (“SIG E. CAPS”)

Sleep
Interest
Guilt
Energy
Concentration
Appetite
Psychomotor Ds
Suicidal ideation
Hopelessness
Helplessness
Worthlessness
Drugs of Abuse
Drug Intoxication Withdrawal

Alcohol Disinhibition, mood lability, Tremulousness,
Benzodiazepines incoordination, slurred hypertension, tachycardia,
speech, ataxia, blackouts anxiety, psychomotor
(EtOH), respiratory depression agitation, nausea, seizures,
hallucinations, DTs (EtOH)
Barbiturates Respiratory depression Anxiety, seizures,

delirium, life-threatening
cardiovascular collapse
(continued)
Opioids CNS depression, nausea, Increased sympathetic

vomiting, sedation, decreased activity, N/V, diarrhea,
pain perception, decreased diaphoresis, rhinorrhea,
GI motility, pupil constriction, piloerection, yawning,
respiratory depression stomach cramps, myalgias,
arthralgias, restlessness,
anxiety, anorexia
Amphetamines Euphoria, increased attention Post-use “crash”:

Cocaine span, aggressiveness, restlessness, headache,
psychomotor agitation, pupil hunger, severe depression,
dilatation, hypertension, irritability, insomnia/
tachycardia, cardiac hypersomnia, strong
arrhythmias, psychosis psychological craving
(paranoia with amphetamines,
formication with cocaine)
PCP Belligerence, impulsiveness, May have recurrence

psychomotor agitation, of symptoms due to
vertical/horizontal nystagmus, reabsorption in GI tract
hyperthermia, tachycardia,
ataxia, psychosis, homicidality
LSD Altered perceptual states

(hallucinations, distortions
of time and space), elevation
of mood, “bad trips” (panic
reaction), flashbacks
(reexperience of the
sensations in absence of
drug use)
Cannabis Euphoria, anxiety, paranoia,

slowed time, social
withdrawal, increased
appetite, dry mouth,
tachycardia, amotivational
syndrome
Nicotine/ Restlessness, insomnia, Irritability, lethargy,

Caffeine anxiety, anorexia headache, increased
appetite, weight gain
First Aid for the Psychiatry Clerkship, 4e; copyright © 2015 McGraw-Hill. All rights reserved.
Psychiatric Emergencies
Delirium Tremens (DTs):

■■ Typically within 2–4 days after cessation of EtOH but may occur
later.
■■ Delirium, agitation, fever, autonomic hyperactivity, auditory and
visual hallucinations.
■■ Treat aggressively with benzodiazepines and hydration.
Neuroleptic Malignant Syndrome (NMS):
■■ Fever, rigidity, autonomic instability, clouding of consciousness,
elevated WBC/CPK
■■ Withhold neuroleptics, hydrate, consider dantrolene and/or
bromocriptine
■■ Idiosyncratic, time-limited reaction
Serotonin Syndrome:
■■ Precipitated by use of two drugs with serotonin-enhancing properties
(e.g., MAOI + SSRI).
■■ Altered mental status, fever, agitation, tremor, myoclonus, hyperre-
flexia, ataxia, incoordination, diaphoresis, shivering, diarrhea.
■■ Discontinue offending agents, benzodiazepines, consider cyprohep-
tadine.
Tyramine Reaction/Hypertensive Crisis:
■■ Precipitated by ingestion of tyramine containing foods while on
MAOIs.
■■ Hypertension, headache, neck stiffness, sweating, nausea, vomiting,
visual problems. Most serious consequences are stroke and possibly
death.
■■ Treat with nitroprusside or phentolamine.
Acute Dystonia:
■■ Early, sudden onset of muscle spasm: eyes, tongue, jaw, neck; may
lead to laryngospasm requiring intubation.
■■ Treat with benztropine (Cogentin) or diphenhydramine (Benadryl).
Lithium Toxicity:
■■ May occur at any Li level (usually >1.5).
■■ Nausea, vomiting, slurred speech, ataxia, incoordination, myoclonus,
hyperreflexia, seizures, nephrogenic diabetes insipidus, delirium,
coma
■■ Discontinue Li, hydrate aggressively, consider hemodialysis
Tricyclic Antidepressant (TCA) Toxicity:
■■ Primarily anticholinergic effects; cardiac conduction disturbances,
hypotension, respiratory depression, agitation, hallucinations.
■■ CNS stimulation, depression, seizures.
■■ Monitor ECG, activated charcoal, cathartics, supportive treatment.
notes
Chapter 2
EXAMINATION AND DIAGNOSIS
History and Mental Status Examination 12 Diagnosis and Classification 18

Interviewing 12 Diagnosis as per DSM-5 18
Taking the History 13 Diagnostic Testing 18
Mental Status Examination 14 Intelligence Tests 18
Mini-Mental State Examination (MMSE) 17 Objective Personality Assessment Tests 19
Interviewing Skills 17 Projective (Personality) Assessment Tests 19
General Approaches to Types of Patients 17
11
12 Chapter 2 EXAMINATION AND DIAGNOSIS
History and Mental Status Examination
INTERVIEWING
Making the Patient Comfortable

The initial interview is of utmost importance to the psychiatrist. With prac-
WARDS TIP tice, you will develop your own style and learn how to adapt the interview to the
individual patient. In general, start the interview by asking open-ended ques-
The HPI should include information tions and carefully note how the patient responds, as this is critical infor-
about the current episode, including mation for the mental status exam. Consider preparing for the interview by
symptoms, duration, context, stressors, writing down the subheadings of the exam (see Figure 2-1). Find a safe and
and impairment in function. private area to conduct the interview. Use closed-ended questions to obtain the
remaining pertinent information. During the first interview, the psychiatrist
Date and Location:
Identifying Patient Data:
Chief Complaint: Past Medical History:
History of Present Illness:
Allergies:
Past Psychiatric History: Current Meds:
First contact:
Developmental History:
Diagnosis:
Prior hospitalizations:
Relationships (children/marital status):
Suicide attempts:
Outpatient treatment:
Education:
Med trials:
Work History:
Substance History: Military History:
Housing:
Smoking: Income:
Family Psychiatric History: Religion:
Legal History:
FIGURE 2-1. Psychiatric history outline.

EXAMINATION AND DIAGNOSIS Chapter 2 13
must establish a meaningful rapport with the patient in order to get accu-
rate and pertinent information. This requires that questions be asked in a WARDS TIP
quiet, comfortable setting so that the patient is at ease. The patient should
feel that the psychiatrist is interested, nonjudgmental, and compassionate. If you are seeing the patient in the ER,
In psychiatry, the history is the most important factor in formulating a diag- make sure to ask how they got to the
nosis and treatment plan. ER (police, bus, walk-in, family member)
and look to see what time they were
triaged. For all initial evaluations, ask
why the patient is seeking treatment
today as opposed to any other day.
TA K I N G T H E H I S T O R Y
The psychiatric history follows a similar format as the history for other types of
patients. It should include the following: WARDS TIP
■■ Identifying data: The patient’s name, gender, age, race, marital status,
place and type of residence, occupation. When taking a substance history,
■■ Chief complaint (use the patient’s own words). If called as a consultant, remember to ask about caffeine and
list reason for the consult. nicotine use. If a heavy smoker is
■■ Sources of information. hospitalized and does not have access
■■ History of present illness (HPI): to nicotine replacement therapy,
■■ The 4 Ps: The patient’s psychosocial and environmental conditions pre- nicotine withdrawal may cause anxiety
disposing to, precipitating, perpetuating, and protecting against the cur- and agitation.
rent episode.
■■ The patient’s support system (whom the patient lives with, distance and
level of contact with friends and relatives).

■■ Neurovegetative symptoms (quality of sleep, appetite, energy, psycho- KEY FACT
motor retardation/activation, concentration).
■■ Suicidal ideation/homicidal ideation. Importance of asking about OTC use:
■■ How work and relationship have been affected (for most diagnoses in Nonsteroidal anti-inflammatory drugs
the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (NSAIDs) can ↓ lithium excretion → ↑
[DSM-5] there is a criterion that specifies that symptoms must cause lithium concentrations (exceptions may
clinically significant distress or impairment in social, occupational, or be sulindac and aspirin).
other important areas of functioning).
■■ Psychotic symptoms (e.g., auditory and visual hallucinations).
■■ Establish a baseline of mental health:
■■ Patient’s level of functioning when “well” WARDS TIP

■■ Goals (outpatient setting)
■■ Past psychiatric history (include as applicable: history of suicide attempts, Psychomotor retardation, which
history of self-harm [e.g., cutting, burning oneself], information about pre- refers to the slowness of voluntary
vious episodes, other psychiatric disorders in remission, medication trials, and involuntary movements, may
past psychiatric hospitalizations, current psychiatrist). also be referred to as hypokinesia or
■■ Substance history (history of intravenous drug use, participation in outpa- bradykinesia. The term akinesia is used
tient or inpatient drug rehab programs). in extreme cases where absence of
■■ Medical history (ask specifically about head trauma, seizures, pregnancy status). movement is observed.
■■ Family psychiatric and medical history (include suicides and treatment
response as patient may respond similarly).
■■ Medications (ask about supplements and over-the-counter medications).
■■ Allergies: Clarify if it was a true allergy or an adverse drug event (e.g., KEY FACT
abdominal pain).
■■ Developmental history: Achieved developmental milestones on time, Automatisms are spontaneous,
friends in school, performance academically. involuntary movements that occur
■■ Social history: Include income source, employment, education, place of during an altered state of consciousness
residence, who they live with, number of children, support system, reli- and can range from purposeful to
gious affiliation and beliefs, legal history, amount of exercise, history of disorganized.
trauma or abuse.
M E N TA L S TAT U S E X A M I N AT I O N
WARDS TIP
This is analogous to performing a physical exam in other areas of medicine. It
A hallmark of pressured speech is
is the nuts and bolts of the psychiatric exam. It should describe the patient in
that it is usually uninterruptible and
as much detail as possible. The mental status exam assesses the following:
the patient is compelled to continue
speaking. ■■ Appearance
■■ Behavior
■■ Speech
■■ Mood/Affect
KEY FACT ■■ Thought Process
■■ Thought Content
An example of inappropriate affect is a ■■ Perceptual Disturbances
patient’s laughing when being told he ■■ Cognition
has a serious illness. ■■ Insight
■■ Judgment/Impulse Control
The mental status exam tells only about the mental status at that moment; it
can change every hour or every day, etc.
KEY FACT
You can roughly assess a patient’s

Appearance/Behavior
intellectual functioning by utilizing the ■■ Physical appearance: Gender, age (looks older/younger than stated age),
proverb interpretation and vocabulary type of clothing, hygiene (including smelling of alcohol, urine, feces),
strategies. Proverb interpretation is posture, grooming, physical abnormalities, tattoos, body piercings. Take
helpful in assessing whether a patient specific notice of the following, which may be clues for possible diagnoses:
has difficulty with abstraction. Being ■■ Pupil size: Drug intoxication/withdrawal.
able to define a particular vocabulary ■■ Bruises in hidden areas: ↑ suspicion for abuse.
word correctly and appropriately use ■■ Needle marks/tracks: Drug use.
it in a sentence reflects a person’s ■■ Eroding of tooth enamel: Eating disorders (from vomiting).
intellectual capacity. ■■ Superficial cuts on arms: Self-harm.
■■ Behavior and psychomotor activity: Attitude (cooperative, seductive, flat-

tering, charming, eager to please, entitled, controlling, uncooperative,
hostile, guarded, critical, antagonistic, childish), mannerisms, tics, eye
WARDS TIP contact, activity level, psychomotor retardation/activation, akathisia,
automatisms, catatonia, choreoathetoid movements, compulsions, dysto-
nias, tremor.
To assess mood, just ask, “How are you
feeling today?” It can also be helpful to
have patients rate their stated mood on Speech
a scale of 1–10. Rate (pressured, slowed, regular), rhythm (i.e., prosody), articulation (dysarthria,
stuttering), accent/dialect, volume/modulation (loudness or softness), tone,
long or short latency of speech.
WARDS TIP Mood

Mood is the emotion that the patient tells you he feels, often in quotations.
A patient who is laughing one second
and crying the next has a labile affect. Affect
Affect is an assessment of how the patient’s mood appears to the examiner,
including the amount and range of emotional expression. It is described with
the following dimensions:
WARDS TIP
■■ Type of affect: Euthymic, euphoric, neutral, dysphoric.
A patient who giggles while telling ■■ Quality/Range describes the depth and range of the feelings shown.
you that he set his house on fire and Parameters: flat (none)—blunted (shallow)—constricted (limited)—full
is facing criminal charges has an (average)—intense (more than normal).
inappropriate affect. ■■ Motility describes how quickly a person appears to shift emotional states.
Parameters: sluggish—supple—labile.
■■ Appropriateness to content describes whether the affect is congru-

ent with the subject of conversation or stated mood. Parameters: WARDS TIP
appropriate—not appropriate.
A patient who remains expressionless
and monotone even when discussing
Thought Process extremely sad or happy moments in his
The patient’s form of thinking—how he or she uses language and puts ideas life has a flat affect.
together. It describes whether the patient’s thoughts are logical, meaningful,
and goal directed. It does not comment on what the patient thinks, only how
the patient expresses his or her thoughts. Circumstantiality is when the point
of the conversation is eventually reached but with overinclusion of trivial or
irrelevant details. Examples of thought disorders include: KEY FACT
■■ Tangentiality: Point of conversation never reached; responses usually in
the ballpark. Examples of delusions:
■■ Loosening of associations: No logical connection from one thought to ■■ Grandeur—belief that one has
another. special powers or is someone
■■ Flight of ideas: Thoughts change abruptly from one idea to another, usu- important (Jesus, President)
ally accompanied by rapid/pressured speech. ■■ Paranoid—belief that one is being
■■ Neologisms: Made-up words. persecuted

■■ Word salad: Incoherent collection of words. ■■ Reference—belief that some event
■■ Clang associations: Word connections due to phonetics rather than actual is uniquely related to patient (e.g.,
meaning. “My car is red. I’ve been in bed. It hurts my head.” a TV show character is sending
■■ Thought blocking: Abrupt cessation of communication before the idea is patient messages)
finished. ■■ Thought broadcasting—belief that
one’s thoughts can be heard by

others
Thought Content ■■ Religious—conventional beliefs
Describes the types of ideas expressed by the patient. Examples of exaggerated (e.g., Jesus talks to me)
■■ Somatic—false belief concerning
disorders:
body image (e.g., I have cancer)
■■ Poverty of thought versus overabundance: Too few versus too many ideas
expressed.
■■ Delusions: Fixed, false beliefs that are not shared by the person’s culture
and cannot be changed by reasoning. Delusions are classified as bizarre
(impossible to be true) or nonbizarre (at least possible).
■■ Suicidal and homicidal ideation: Ask if the patient feels like harming WARDS TIP
him/herself or others. Identify if the plan is well formulated. Ask if the
patient has an intent (i.e., if released right now, would he go and kill him- The following question can help screen
self or harm others?). Ask if the patient has means to kill himself (firearms for compulsions: Do you clean, check,
in the house/multiple prescription bottles). or count things on a repetitive basis?
■■ Phobias: Persistent, irrational fears.
■■ Obsessions: Repetitive, intrusive thoughts.
■■ Compulsions: Repetitive behaviors (usually linked with obsessive thoughts).
Perceptual Disturbances WARDS TIP

■■ Hallucinations: Sensory perceptions that occur in the absence of an actual
stimulus. An auditory hallucination that instructs
■■ Describe the sensory modality: Auditory (most common), visual, taste, a patient to harm himself or others is
olfactory, or tactile. an important risk factor for suicide or
■■ Describe the details (e.g., auditory hallucinations may be ringing, homicide.
humming, whispers, or voices speaking clear words). Command
auditory hallucinations are voices that instruct the patient to do
something.
■■ Ask if the hallucination is experienced only before falling asleep
(hypnagogic hallucination) or upon awakening (hypnopompic hal

lucination).
■■ Illusions: Inaccurate perception of existing sensory stimuli (e.g., wall

appears as if it’s moving).
■■ Derealization/Depersonalization: The experience of feeling detached from
one’s surroundings/mental processes.
Sensorium and Cognition

Sensorium and cognition are assessed in the following ways:
■■ Consciousness: Patient’s level of awareness; possible range includes:
WARDS TIP Alert—drowsy—lethargic—stuporous—coma.
■■ Orientation: To person, place, and time.
Alcoholic hallucinosis refers to ■■ Calculation: Ability to add/subtract.
hallucinations (usually auditory, ■■ Memory:
■■ Immediate (registration)—dependent on attention/concentration and
although visual and tactile may occur)
that occur either during or after a can be tested by asking a patient to repeat several digits or words.
■■ Recent (short-term memory)—events within the past few minutes,
period of heavy alcohol consumption.
Patients usually are aware that these hours or days.
■■ Remote memory (long-term memory).
hallucinations are not real. In contrast
to delirium tremens (DTs), there is no ■■ Fund of knowledge: Level of knowledge in the context of the patient’s
clouding of sensorium and vital signs culture and education (e.g., Who is the president? Who was Picasso?).
are normal. ■■ Attention/Concentration: Ability to subtract serial 7s from 100 or to spell
“world” backwards.
■■ Reading/Writing: Simple sentences (must make sure the patient is literate
first).
■■ Abstract concepts: Ability to explain similarities between objects and
understand the meaning of simple proverbs.
Insight
Insight is the patient’s level of awareness and understanding of his or her
problem. Problems with insight include complete denial of illness or blaming
it on something else. Insight can be described as full, partial/limited, or none.
Judgment
Judgment is the patient’s ability to understand the outcome of his or her
actions and use this awareness in decision making. Best determined from
information from the HPI and recent behavior (e.g., how a patient was
brought to treatment or medication compliance). Judgment can be described
as excellent, good, fair, or poor.
Mrs. Gong is a 52-year-old Asian-American woman who arrives at

the emergency room reporting that her deceased husband of 25
years told her that he would be waiting for her there. In order to meet
him, she drove nonstop for 22 hours from a nearby state. She claims that
her husband is a famous preacher and that she, too, has a mission from
God. Although she does not specify the details of her mission, she says
that she was given the ability to stop time until her mission is completed.
She reports experiencing high levels of energy despite not sleeping for
22 hours. She also reports that she has a history of psychiatric hospital-
izations but refuses to provide further information.
While obtaining her history you perform a mental status exam. Her
appearance is that of a woman who looks older than her stated age.
She is obese and unkempt. There is no evidence of tattoos or piercings.
She has tousled hair and is dressed in a mismatched flowered skirt and
a red T-shirt. Upon her arrival at the emergency room, her behavior is
demanding, as she insists that you let her husband know that she has
arrived. She then becomes irate and proceeds to yell, banging her head
against the wall. She screams, “Stop hiding him from me!” She is unco-
operative with redirection and is guarded during the remainder of the
interview. Her eye contact is poor as she is looking around the room.
Her psychomotor activity is agitated. Her speech is loud and pressured,
with a foreign accent.
She reports that her mood is “angry,” and her affect as observed during
the interview is labile and irritable.
Her thought process includes flight of ideas. Her thought content is

significant for delusions of grandeur and thought broadcasting, as evi-
denced by her refusing to answer most questions claiming that you are
able to know what she is thinking. She denies suicidal or homicidal ide-
ation. She expresses disturbances in perception as she admits to fre-
quent auditory hallucinations of command.
She is uncooperative with formal cognitive testing, but you notice that
she is oriented to place and person. However, she erroneously states that
it is 2005. Her attention and concentration are notably impaired, as she
appears distracted and frequently needs questions repeated. Her insight,
judgment, and impulse control are determined to be poor.
You decide to admit Mrs. Gong to the inpatient psychiatric unit in order
to allow for comprehensive diagnostic evaluation, the opportunity to
obtain collateral information from her prior hospitalizations, safety mon-
itoring, medical workup for possible reversible causes of her symptoms,
and psychopharmacological treatment.
M I N I - M E N TA L S TAT E E X A M I N AT I O N ( M M S E )
The MMSE is a simple, brief test used to assess gross cognitive functioning.
See the Cognitive Disorders chapter for detailed description. The areas tested
include:
■■ Orientation (to person, place, and time).
■■ Memory (immediate—registering three words; and recent—recalling
three words 5 minutes later).
■■ Concentration and attention (serial 7s, spell “world” backwards).
■■ Language (naming, repetition, comprehension).
■■ Complex command.
■■ Visuospatial ability (copy of design).
Interviewing Skills
G E N E R A L A P P R O A C H E S T O T Y P E S O F PAT I E N T S
Violent Patient
One should avoid being alone with a potentially violent patient. Inform
staff of your whereabouts. Know if there are accessible panic buttons. To
assess violence or homicidality, one can simply ask, “Do you feel like you
want to hurt someone or that you might hurt someone?” If the patient
WARDS TIP expresses imminent threats against friends, family, or others, the doctor
should notify potential victims and/or protection agencies when appropri-
To test ability to abstract, ask: ate (Tarasoff rule).
1. Similarities: How are an apple and
orange alike? (Normal answer: “They
are fruits.” Concrete answer: “They are Delusional Patient
round.”) Although the psychiatrist should not directly challenge a delusion or insist
2. Proverb testing: What is meant by that it is untrue, he should not imply he believes it either. He should simply
the phrase, “You can’t judge a book acknowledge that he understands the patient believes the delusion is true.
by its cover?” (Normal answer: “You
can’t judge people just by how they
look.” Concrete answer: “Books have Depressed Patient
different covers.”) A depressed patient may be skeptical that he or she can be helped. It is impor-
tant to offer reassurance that he or she can improve with appropriate therapy.
Inquiring about suicidal thoughts is crucial; a feeling of hopelessness, sub-
stance use, and/or a history of prior suicide attempts reveal an ↑ risk for sui-
cide. If the patient is actively planning or contemplating suicide, he or she
should be hospitalized or otherwise protected.
KEY FACT
A prior history of violence is the most Diagnosis and Classification

important predictor of future violence.
DIAGNOSIS AS PER DSM-5
The American Psychiatric Association uses a criterion-based system for diag-

noses. Criteria and codes for each diagnosis are outlined in the DSM-5.
WARDS TIP
In assessing suicidality, do not simply

ask, “Do you want to hurt yourself?” Diagnostic Testing
because this does not directly address
suicidality (he may plan on dying in
a painless way). Ask directly about INTELLIGENCE TESTS
killing self or suicide. If contemplating
suicide, ask the patient if he has a plan Aspects of intelligence include memory, logical reasoning, ability to assimilate
of how to do it and if he has intent; a factual knowledge, understanding of abstract concepts, etc.
detailed plan, intent, and the means to
accomplish it suggest a serious threat. Intelligence Quotient (IQ)
IQ is a test of intelligence with a mean of 100 and a standard deviation of
15. These scores are adjusted for age. An IQ of 100 signifies that mental age
equals chronological age and corresponds to the 50th percentile in intellec-
tual ability for the general population.
KEY FACT
Intelligence tests assess cognitive function by evaluating comprehension, fund
of knowledge, math skills, vocabulary, picture assembly, and other verbal and
The Minnesota Multiphasic Personality
performance skills. Two common tests are:
Inventory (MMPI) is an objective
psychological test that is used to assess
Wechsler Adult Intelligence Scale (WAIS):
a person’s personality and identify
psychopathologies. The mean score ■■ Most common test for ages 16–90.
for each scale is 50 and the standard ■■ Assesses overall intellectual functioning.
deviation is 10. ■■ Four index scores: Verbal comprehension, perceptual reasoning, working
memory, processing speed.
Wechsler Intelligence Scale for Children (WISC): Tests intellectual ability in

patients ages 6–16. WARDS TIP
IQ Chart
OBJECTIVE PERSONALIT Y ASSESSMENT TESTS Very superior: >130
Superior: 120–129
These tests are questions with standardized-answer format that can be objec- High average: 110–119
tively scored. The following is an example: Average: 90–109
Low average: 80–89
Minnesota Multiphasic Personality Inventory (MMPI-2) Borderline: 70–79
■■ Tests personality for different pathologies and behavioral patterns. Extremely low (intellectual
■■ Most commonly used. disability): <70
PROJECTIVE (PERSONALIT Y) ASSESSMENT TESTS
Projective tests have no structured-response format. The tests often ask for
interpretation of ambiguous stimuli. Examples are:
Thematic Apperception Test (TAT)

■■ Test taker creates stories based on pictures of people in various situations.
■■ Used to evaluate motivations behind behaviors.
Rorschach Test
■■ Interpretation of inkblots.
■■ Used to identify thought disorders and defense mechanisms.
This page intentionally left blank
Chapter 3
PSYCHOTIC DISORDERS
Psychosis 22 Pathophysiology of Schizophrenia: The Dopamine Hypothesis 26

Delusions 22 Other Neurotransmitter Abnormalities Implicated in Schizophrenia 27
Perceptual Disturbances 22 Prognostic Factors 27
Differential Diagnosis of Psychosis 22 Treatment 27
Psychotic Disorder Due to Another Medical Condition 23 Schizophreniform Disorder 29
Substance/Medication-Induced Psychotic Disorder 23
Schizoaffective Disorder 29
Schizophrenia 23
Brief Psychotic Disorder 30
Positive, Negative, and Cognitive Symptoms 24
Three Phases 24 Delusional Disorder 30
Diagnosis of Schizophrenia 24 Culture-Specific Psychoses 31
Psychiatric Exam of Patients with Schizophrenia 25
Comparing Time Courses and Prognoses of
Epidemiology 26
Psychotic Disorders 31
Downward Drift 26
Quick and Easy Distinguishing Features 31
21
22 Chapter 3 PSYCHOTIC DISORDERS
Psychosis
Psychosis is a general term used to describe a distorted perception of real-
WARDS TIP ity. Poor reality testing may be accompanied by delusions, perceptual distur-
bances (illusions or hallucinations), and/or disorganized thinking/ behavior.
Psychosis is exemplified by either Psychosis can be a symptom of schizophrenia, mania, depression, delirium,
delusions, hallucinations, or severe and dementia, and it can be substance or medication-induced.
disorganization of thought/behavior.
DELUSIONS
Delusions are fixed, false beliefs that remain despite evidence to the contrary
and cannot be accounted for by the cultural background of the individual.
They can be categorized as either bizarre or nonbizarre. A nonbizarre delu-

sion is a false belief that is plausible but is not true. Example: “The neighbors
are spying on me by reading my mail.” A bizarre delusion is a false belief that
is impossible. Example: “A Martian fathered my baby and inserted a micro-
chip in my brain.”
Delusions can also be categorized by theme:

■■ Delusions of persecution/paranoid delusions: Irrational belief that one is
being persecuted. Example: “The CIA is after me and tapped my phone.”
■■ Ideas of reference: Belief that cues in the external environment are
uniquely related to the individual. Example: “The TV characters are
speaking directly to me.”
■■ Delusions of control: Includes thought broadcasting (belief that one’s
thoughts can be heard by others) and thought insertion (belief that others’
thoughts are being placed in one’s head).
■■ Delusions of grandeur: Belief that one has special powers beyond those of
a normal person. Example: “I am the all-powerful son of God and I shall
bring down my wrath on you if I don’t get my way.”
■■ Delusions of guilt: Belief that one is guilty or responsible for something.
Example: “I am responsible for all the world’s wars.”
■■ Somatic delusions: Belief that one is infected with a disease or has a cer-
tain illness.
P e r c ep t u a l D is t u r b a n c es
■■ Illusion: Misinterpretation of an existing sensory stimulus (such as mistak-

ing a shadow for a cat).
■■ Hallucination: Sensory perception without an actual external stimulus.
WARDS TIP ■■ Auditory: Most commonly exhibited by schizophrenic patients.
■■ Visual: Occurs but less common in schizophrenia. May accompany

Auditory hallucinations that directly tell drug intoxication, drug and alcohol withdrawal, or delirium.
the patient to perform certain acts are ■■ Olfactory: Usually an aura associated with epilepsy.
called command hallucinations. ■■ Tactile: Usually secondary to drug use or alcohol withdrawal.
D i f f e r en t i a l D i a g nosis o f P s y c h osis
■■ Psychotic disorder due to another medical condition

■■ Substance/Medication-induced psychotic disorder
■■ Delirium/Dementia
■■ Bipolar disorder, manic/mixed episode
■■ Major depression with psychotic features
PSYCHOTIC DISORDERS Chapter 3 23
■■ Brief psychotic disorder

■■ Schizophrenia WARDS TIP
■■ Schizophreniform disorder
■■ Schizoaffective disorder It’s important to be able to distinguish
■■ Delusional disorder between a delusion, illusion, and
hallucination. A delusion is a false belief,
an illusion is a misinterpretation of an
P S YCH O T I C diso r de r due t o a no t h e r M edi c a l Condi t ion external stimulus, and a hallucination
is perception in the absence of an
Medical causes of psychosis include: external stimulus.
1. Central nervous system (CNS) disease (cerebrovascular disease, multiple
sclerosis, neoplasm, Alzheimer’s disease, Parkinson’s disease, Huntington’s
disease, tertiary syphilis, epilepsy [often temporal lobe], encephalitis, prion
disease, neurosarcoidosis, AIDS).
2. Endocrinopathies (Addison/Cushing disease, hyper/hypothyroidism, hyper/
hypocalcemia, hypopituitarism).
3. Nutritional/Vitamin deficiency states (B12, folate, niacin).
4. Other (connective tissue disease [systemic lupus erythematosus, temporal
arteritis], porphyria).
DSM-5 criteria for psychotic disorder due to another medical condition include:
■■ Prominent hallucinations or delusions. WARDS TIP
■■ Symptoms do not occur only during an episode of delirium.
■■ Evidence from history, physical, or lab data to support another medical Elderly, medically ill patients who
cause (i.e., not psychiatric). present with psychotic symptoms such
as hallucinations, confusion, or paranoia
should be carefully evaluated for
S u b s ta n c e / M edi c at ion - indu c ed ps y c h o t i c diso r de r
delirium, which is a far more common
finding in this population.
Prescription medications that may cause psychosis in some patients include
anesthetics, antimicrobials, corticosteroids, antiparkinsonian agents, anti-
convulsants, antihistamines, anticholingerics, antihypertensives, NSAIDs,
digitalis, methylphenidate, and chemotherapeutic agents. Substances such as
alcohol, cocaine, hallucinogens (LSD, Ecstasy), cannabis, benzodiazepines,
barbiturates, inhalants, and phencyclidine (PCP) can cause psychosis, either
in intoxication or withdrawal.
DSM-5 Criteria
WARDS TIP
■■ Hallucinations and/or delusions.
■■ Symptoms do not occur only during episode of delirium. To make the diagnosis of schizophrenia,
■■ Evidence from history, physical, or lab data to support a medication or a patient must have symptoms of the
substance-induced cause. disease for at least 6 months.
■■ Disturbance is not better accounted for by a psychotic disorder that is not
substance/medication-induced.
Schizophrenia
A 24-year-old male graduate student without prior medical or psy-

chiatric history is reported by his mother to have been very anxious
over the past 9 months, with increasing concern that people are watch-
ing him. He now claims to “hear voices” telling him what must be done
to “fix the country.” Important workup? Thyroid-stimulating hormone
(TSH), rapid plasma reagin (RPR), brain imaging. Likely diagnosis?
Schizophrenia. Next step? Antipsychotics.
Schizophrenia is a psychiatric disorder characterized by a constellation of

abnormalities in thinking, emotion, and behavior. There is no single symp-
tom that is pathognomonic, and there is a heterogeneous clinical presenta-
tion. Schizophrenia is typically chronic, with significant psychosocial and
medical consequences to the patient.
P O S I T I V E, N E GAT I V E, A N D C O G N I T I V E S Y M P T O M S
In general, the symptoms of schizophrenia are broken up into three

categories:
KEY FACT
■■ Positive symptoms: Hallucinations, delusions, bizarre behavior, disorganized
Think of positive symptoms as things speech. These tend to respond more robustly to antipsychotic medications.
that are ADDED onto normal behavior. ■■ Negative symptoms: Flat or blunted affect, anhedonia, apathy, alogia, and
Think of negative symptoms as things lack of interest in socialization. These symptoms are comparatively more
that are SUBTRACTED or missing from often treatment resistant and contribute significantly to the social isolation
normal behavior. of schizophrenic patients.
■■ Cognitive symptoms: Impairments in attention, executive function,
and working memory. These symptoms may → poor work and school
performance.
WARDS TIP
THR E E P HA S E S
Stereotyped movement, bizarre
posturing, and muscle rigidity
Symptoms of schizophrenia often present in three phases:
are examples of catatonia seen in
schizophrenic patients. 1. Prodromal: Decline in functioning that precedes the first psychotic episode.
The patient may become socially withdrawn and irritable. He or she may
have physical complaints, declining school/work performance, and/or new-
found interest in religion or the occult.
2. Psychotic: Perceptual disturbances, delusions, and disordered thought
process/content.
3. Residual: Occurs following an episode of active psychosis. It is marked by
mild hallucinations or delusions, social withdrawal, and negative symptoms.
KEY FACT
D I AG N O S I S O F S CH I Z O P HR E N I A
Clozapine is typically considered
for treating schizophrenia when a DSM-5 Criteria
patient fails both typical and other
■■ Two or more of the following must be present for at least 1 month:
atypical antipsychotics; this is due
1. Delusions
to the potential rare adverse event,
2. Hallucinations
agranulocytosis, which requires patients
3. Disorganized speech
be monitored (WBC and ANC counts)
4. Grossly disorganized or catatonic behavior
regularly.
5. Negative symptoms
Note: At least one must be 1, 2, or 3.
■■ Must cause significant social, occupational, or self-care functional
deterioration.
WARDS TIP ■■ Duration of illness for at least 6 months (including prodromal or residual
periods in which the above full criteria may not be met).
The 5 A’s of schizophrenia (negative ■■ Symptoms not due to effects of a substance or another medical condition.
symptoms):
1. Anhedonia
2. Affect (flat) Mr. Torres is a 21-year-old man who is brought to the ER by his
3. Alogia (poverty of speech) mother after he began talking about “aliens” who were trying to steal
4. Avolition (apathy) his soul. Mr. Torres reports that aliens left messages for him by arrang-
5. Attention (poor) ing sticks outside his home and sometimes send thoughts into his mind.
On exam, he is guarded and often stops talking while in the middle of WARDS TIP
expressing a thought. Mr. Torres appears anxious and frequently scans
the room for aliens, which he thinks may have followed him to the hos- Echolalia—repeats words or phrases
pital. He denies any plan to harm himself, but admits that the aliens EchoPRAxia—mimics behavior
sometimes want him to throw himself in front of a car, “as this will (PRActices behavior)
change the systems that belong under us.”
The patient’s mother reports that he began expressing these ideas a

few months ago, but that they have become more severe in the last few
weeks. She reports that during the past year, he has become isolated
from his peers, frequently talks to himself, and has stopped going to
community college. He has also spent most of his time reading science
fiction books and creating devices that will prevent aliens from hurt-
ing him. She reports that she is concerned because the patient’s father,
who left while the patient was a child, exhibited similar symptoms many
years ago and has spent most of his life in psychiatric hospitals.
What is Mr. Torres’s most likely diagnosis? What differential diagnoses

should be considered?
Mr. Torres’s most likely diagnosis is schizophrenia. He exhibits delu-

sional ideas that are bizarre and paranoid in nature. He also reports the
presence of frequent auditory hallucinations and disturbances in thought
process that include thought blocking. Although the patient’s mother
reports that his psychotic symptoms began “a few months ago,” the
patient has exhibited social and occupational dysfunction during the last
year. Mr. Torres quit school, became isolated, and has been responding
to internal stimuli since that time. In addition, his father appears to also
suffer from a psychotic disorder. In this case, it appears that the disorder
has been present for more than 6 months; however, if this is unclear, the
diagnosis of schizophreniform disorder should be made instead.
The differential diagnosis should also include schizoaffective disorder,

medication/substance-induced psychotic disorder, psychotic disorder
due to another medical condition, and mood disorder with psychotic
features.
What would be appropriate steps in the acute management of this

patient?
Treatment should include inpatient hospitalization in order to provide

a safe environment, with monitoring of suicidal ideation secondary to
his psychosis. Routine laboratory tests, including a urine or serum drug
screen, should be undertaken. The patient should begin treatment with
antipsychotic medication while closely being monitored for potential
side effects.
KEY FACT
P S YCH I ATR I C E X A M O F PAT I E N T S W I TH S CH I Z O P HR E N I A
Brief psychotic disorder lasts for < 1
The typical findings in schizophrenic patients include: month. Schizophreniform disorder
■■ Disheveled appearance can last between 1 and 6 months.
■■ Flat affect Schizophrenia lasts for > 6 months.
■■ Disorganized thought process
■■ Intact procedural memory and orientation

■■ Auditory hallucinations
■■ Paranoid delusions
■■ Ideas of reference
■■ Lack of insight into their disease
KEY FACT E P I D E M I O LO GY
■■ Schizophrenia affects approximately 0.3–0.7% of people over their lifetime.

People born in late winter and early
■■ Men and women are equally affected but have different presentations and
spring have a higher incidence of
outcomes:
schizophrenia for unknown reasons.
■■ Men tend to present in early to mid-20s
(One theory involves seasonal variation
■■ Women present in late 20s
in viral infections, particularly second
■■ Men tend to have more negative symptoms and poorer outcome com-
trimester exposure to influenza virus.)
pared to women.
■■ Schizophrenia rarely presents before age 15 or after age 55.
■■ There is a strong genetic predisposition:
■■ 50% concordance rate among monozygotic twins
■■ 40% risk of inheritance if both parents have schizophrenia
■■ 12% risk if one first-degree relative is affected
■■ Substance use is comorbid in many patients with schizophrenia. The most

commonly abused substance is nicotine (> 50%), followed by alcohol,
cannabis, and cocaine.
■■ Post-psychotic depression is the phenomenon of schizophrenic patients
developing a major depressive episode after resolution of their psychotic
symptoms.
KEY FACT D O W N W AR D D R I FT
Lower socioeconomic groups have higher rates of schizophrenia. This may be

Schizophrenia is found in lower
due to the downward drift hypothesis, which postulates that people suffering
socioeconomic groups likely due to
from schizophrenia are unable to function well in society and hence end up
“downward drift” (they have difficulty in
in lower socioeconomic groups. Many homeless people in urban areas suffer
holding good jobs, so they tend to drift
from schizophrenia.
downward socioeconomically).
PATH O P HY S I O LO GY O F S CH I Z O P HR E N I A : TH E D O PA M I N E HY P O TH E S I S
Though the exact cause of schizophrenia is not known, it appears to be partly

related to ↑ dopamine activity in certain neuronal tracts. Evidence to support
this hypothesis is that most antipsychotics successful in treating schizophrenia
are dopamine receptor antagonists. In addition, cocaine and amphetamines ↑
dopamine activity and can → schizophrenic-like symptoms.
KEY FACT Theorized Dopamine Pathways Affected in Schizophrenia

■■ Prefrontal cortical: Inadequate dopaminergic activity responsible for nega-
Akathisia is an unpleasant, subjective tive symptoms.
sense of restlessness and need to move, ■■ Mesolimbic: Excessive dopaminergic activity responsible for positive
often manifested by the inability to sit symptoms.
still.
Other Important Dopamine Pathways Affected by antipsychotics
■■ Tuberoinfundibular: Blocked by antipsychotics, causing hyperprolactinemia,
which may → gynecomastia, galactorrhea, sexual dysfunction, and men-
KEY FACT strual irregularities.
■■ Nigrostriatal: Blocked by antipsychotics, causing Parkinsonism/extrapyra-
The lifetime prevalence of midal side effects such as tremor, rigidity, slurred speech, akathisia, dysto-
schizophrenia is 0.3–0.7%. nia, and other abnormal movements.
O TH E R N E U R O TRA N S M I TT E R AB N O R M A L I T I E S I M P L I CAT E D
KEY FACT
I N S CH I Z O P HR E N I A
Schizophrenia has a large genetic
■■ Elevated serotonin: Some of the second-generation (atypical) antipsy-
component. If one identical twin has
chotics (e.g., risperidone and clozapine) antagonize serotonin and weakly
schizophrenia, the risk of the other
antagonize dopamine.
identical twin having schizophrenia
■■ Elevated norepinephrine: Long-term use of antipsychotics has been
is 50%. A biological child of a
shown to ↓ activity of noradrenergic neurons.
schizophrenic person has a higher
■■ ↓ gamma-aminobutyric acid (GABA): There is ↓ expression of the
chance of developing schizophrenia,
enzyme necessary to create GABA in the hippocampus of schizophrenic
even if adopted.
patients.
■■ ↓ levels of glutamate receptors: Schizophrenic patients have fewer
NMDA receptors; this corresponds to the psychotic symptoms observed
with NMDA antagonists like ketamine.
P R O G N O S T I C FACT O R S
Even with medication, 40–60% of patients remain significantly impaired KEY FACT
after their diagnosis, while only 20–30% function fairly well in society. About
20% of patients with schizophrenia attempt suicide and many more experi- Computed tomographic (CT) and
ence suicidal ideation. Several factors are associated with a better or worse magnetic resonance imaging (MRI)
prognosis: scans of patients with schizophrenia
may show enlargement of the
Associated with Better Prognosis ventricles and diffuse cortical atrophy
■■ Later onset and reduced brain volume.
■■ Good social support
■■ Positive symptoms
■■ Mood symptoms
■■ Acute onset
■■ Female gender
■■ Few relapses
■■ Good premorbid functioning
Associated with Worse Prognosis KEY FACT

■■ Early onset
■■ Poor social support

Schizophrenia often involves
■■ Negative symptoms
neologisms. A neologism is a newly
■■ Family history
coined word or expression that has
■■ Gradual onset
meaning only to the person who
■■ Male gender
uses it.
■■ Many relapses
■■ Poor premorbid functioning (social isolation, etc.)
■■ Comorbid substance use
TR E AT M E N T
A multimodal approach is the most effective, and therapy must be tailored to

the needs of the specific patient. Pharmacologic treatment consists primar-
WARDS TIP
ily of antipsychotic medications, otherwise known as neuroleptics. (For more
detail, see the Psychopharmacology chapter.)
First-generation antipsychotic
■■ First-generation (or typical) antipsychotic medications (e.g., chlorproma- medications are referred to as typical
zine, fluphenazine, haloperidol, perphenazine): or conventional antipsychotics (often
■■ These are primarily dopamine (mostly D2) antagonists. called neuroleptics). Second-generation
■■ Treat positive symptoms with minimal impact on negative symptoms. antipsychotic medications are referred
■■ Side effects include extrapyramidal symptoms, neuroleptic malignant to as atypical antipsychotics.
syndrome, and tardive dyskinesia (see below).
■■ Second-generation (or atypical) antipsychotic medications (e.g., aripip-

WARDS TIP razole, asenapine, clozapine, iloperidone, lurasidone, olanzapine, quetiap-
ine, risperidone, ziprasidone):
Schizophrenic patients who are treated ■■ These antagonize serotonin receptors (5-HT2) as well as dopamine
with second-generation (atypical) (D4>D2) receptors.
antipsychotic medications need a ■■ Research has shown no significant difference between first- and second-
careful medical evaluation for metabolic generation antipsychotics in efficacy. The selection requires the weighing
syndrome. This includes checking of benefits and risks in individual clinical cases.
weight, body mass index (BMI), fasting ■■ Lower incidence of extrapyramidal side effects, but ↑ risk for metabolic
blood glucose, lipid assessment, and syndrome.
blood pressure. ■■ Medications should be taken for at least 4 weeks before efficacy is
determined.
■■ Clozapine is reserved for patients who have failed multiple antipsy-
chotic trials due to its ↑ risk of agranulocytosis.

Behavioral therapy attempts to improve patients’ ability to function in soci-
ety. Patients are helped through a variety of methods to improve their social
skills, become self-sufficient, and minimize disruptive behaviors. Family
WARDS TIP therapy and group therapy are also useful adjuncts.
Patients who are treated with

Important Side Effects and Sequelae of Antipsychotic Medications
first-generation (typical) antipsychotic
medication need to be closely Side effects of antipsychotic medications include:
monitored for extrapyramidal 1. Extrapyramidal symptoms (especially with the use of high-potency first-
symptoms, such as acute dystonia generation antipsychotics):
and tardive dyskinesia. ■■ Dystonia (spasms) of face, neck, and tongue
■■ Parkinsonism (resting tremor, rigidity, bradykinesia)
■■ Akathisia (feeling of restlessness)
Treatment: Anticholinergics (benztropine, diphenhydramine), benzodiaz-

epines/beta-blockers (specifically for akathisia)
2. Anticholinergic symptoms (especially low-potency first-generation anti-
psychotics and atypical antipsychotics): Dry mouth, constipation, blurred
KEY FACT vision, hyperthermia.
Treatment: As per symptom (eye drops, stool softeners, etc.)
High-potency antipsychotics (such as 3. Metabolic syndrome (second-generation antipsychotics): A constellation
haloperidol and fluphenazine) have of conditions— ↑ blood pressure, ↑ blood sugar levels, excess body fat
a higher incidence of extrapyramidal around the waist, abnormal cholesterol levels—that occur together, ↑ the
side effects, while low-potency risk for developing cardiovascular disease, stroke, and type 2 diabetes.
antipsychotics (such as chlorpromazine) Treatment: Consider switching to a first-generation antipsychotic or a more
have primarily anticholinergic and “weight-neutral” second-generation antipsychotic such as aripiprazole or
antiadrenergic side effects. ziprasidone. Monitor lipids and blood glucose measurements. Refer the
patient to primary care for appropriate treatment of hyperlipidemia, diabe-
tes, etc. Encourage appropriate diet, exercise, and smoking cessation.
4. Tardive dyskinesia (more likely with first-generation antipsychotics):
Choreoathetoid movements, usually seen in the face, tongue, and head.
Treatment: Discontinue or reduce the medication and consider substituting an
atypical antispsychotic (if appropriate). Benzodiazepines, Botox, and vitamin
E may be used. The movements may persist despite withdrawal of the drug.
WARDS TIP Although less common, atypical antipsychotics can cause tardive dyskinesia.
5. Neuroleptic malignant syndrome (typically high-potency first-generation
Tardive dyskinesia occurs most often antipsychotics):
in older women after at least 6 months ■■ Change in mental status, autonomic instability (high fever, labile blood
of medication. A small percentage of pressure, tachycardia, tachypnea, diaphoresis), “lead pipe” rigidity, elevated
patients will experience spontaneous creatine phosphokinase (CPK) levels, leukocytosis, and metabolic acidosis.
remission, so discontinuation of the ■■ A medical emergency that requires prompt withdrawal of all antipsy-
agent should be considered if clinically chotic medications and immediate medical assessment and treatment.
appropriate. ■■ May be observed in any patient being treated with any antipsychotic
(including second generation) medications at any time, but is more

frequently associated with the initiation of treatment and at higher IV/

IM dosing of high-potency neuroleptics. KEY FACT
■■ Patients with a history of prior neuroleptic malignant syndrome are at
an ↑ risk of recurrent episodes when retrialed with antipsychotic agents. The cumulative risk of developing
6. Prolonged QTc interval and other electrocardiogram changes, hyperp- tardive dyskinesia from antipsychotics
rolactinemia (→ gynecomastia, galactorrhea, amenorrhea, diminished (particularly first generation) is 5% per
libido, and impotence), hematologic effects (agranulocytosis may occur year.
with clozapine, requiring frequent blood draws when this medication
is used), ophthalmologic conditions (thioridazine may cause irrevers-
ible retinal pigmentation at high doses; deposits in lens and cornea may
occur with chlorpromazine), dermatologic conditions (such as rashes and
photosensitivity).
Schizophreniform Disorder
KEY FACT
Diagnosis and DSM-5 Criteria
The diagnosis of schizophreniform disorder is made using the same DSM-5 If a schizophrenia presentation has
criteria as schizophrenia. The only difference between the two is that in not been present for 6 months, think
schizophreniform disorder the symptoms have lasted between 1 and 6 months, schizophreniform disorder.
whereas in schizophrenia the symptoms must be present for > 6 months.
Prognosis
One-third of patients recover completely; two-thirds progress to schizoaffec-
tive disorder or schizophrenia.
Treatment
Hospitalization (if necessary), 6-month course of antipsychotics, and support-
ive psychotherapy.
Schizoaffective Disorder
The diagnosis of schizoaffective disorder is made in patients who:
■■ Meet criteria for either a major depressive or manic episode during which
psychotic symptoms consistent with schizophrenia are also met.
■■ Delusions or hallucinations for 2 weeks in the absence of mood disorder
symptoms (this criterion is necessary to differentiate schizoaffective disor-

der from mood disorder with psychotic features).
■■ Mood symptoms present for a majority of the psychotic illness.
■■ Symptoms not due to the effects of a substance (drug or medication) or
another medical condition.
Prognosis
Worse with poor premorbid adjustment, slow onset, early onset, predominance
of psychotic symptoms, long course, and family history of schizophrenia.
Treatment
■■ Hospitalization (if necessary) and supportive psychotherapy.
■■ Medical therapy: Antipsychotics (second-generation medications may
target both psychotic and mood symptoms); mood stabilizers, antidepres-
sants, or electroconvulsive therapy (ECT) may be indicated for treatment
of mood symptoms.
KEY FACT
Brief Psychotic Disorder
Patients with borderline personality
disorder may have transient, stress-
related psychotic experiences. These Patient with psychotic symptoms as in schizophrenia; however, the symptoms
are considered part of their underlying last from 1 day to 1 month, and there must be eventual full return to pre-
personality disorder and not diagnosed morbid level of functioning. Symptoms must not be due to the effects of a
as a brief psychotic disorder. substance (drug or medication) or another medical condition. This is a rare
diagnosis, much less common than schizophrenia. It may be seen in reaction
to extreme stress such as bereavement, sexual assault, etc.
Prognosis
High rates of relapse, but almost all completely recover.
Treatment
Brief hospitalization (usually required for workup, safety, and stabilization),
supportive therapy, course of antipsychotics for psychosis, and/or benzodiaz-
epines for agitation.
Delusional Disorder
Delusional disorder occurs more often in middle-aged or older patients (after
age 40). Immigrants, the hearing impaired, and those with a family history of
schizophrenia are at increased risk.
To be diagnosed with delusional disorder, the following criteria must be met:
■■ One or more delusions for at least 1 month.
■■ Does not meet criteria for schizophrenia.
■■ Functioning in life not significantly impaired, and behavior not obviously
bizarre.
■■ While delusions may be present in both delusional disorder and schizo-
phrenia, there are important differences (see Table 3-1).
Types of Delusions
Patients are further categorized based on the types of delusions they experience:
■■ Erotomanic type: Delusion that another person is in love with the individual.
■■ Grandiose type: Delusions of having great talent.
■■ Somatic type: Physical delusions.
■■ Persecutory type: Delusions of being persecuted.
TA B L E 3 - 1. Schizophrenia versus Delusional Disorder
Schizophrenia Delusional Disorder
■■ Bizarre or nonbizarre delusions ■■ Usually nonbizarre delusions

■■ Daily functioning significantly impaired ■■ Daily functioning not significantly impaired
■■ Must have two or more of the following: ■■ Does not meet the criteria for schizophrenia
■■ Delusions as described in the left column
■■ Hallucinations
■■ Disorganized speech
■■ Disorganized behavior
■■ Negative symptoms
■■ Jealous type: Delusions of unfaithfulness.

■■ Mixed type: More than one of the above.
■■ Unspecified type: Not a specific type as described above.
Prognosis
■■ Better than schizophrenia with treatment:
■■ > 50%: Full recovery
■■ > 20%: ↓ symptoms
■■ < 20%: No change
Treatment
Difficult to treat, especially given the lack of insight and impairment.
Antipsychotic medications are recommended despite somewhat limited
evidence. Supportive therapy is often helpful, but group therapy should be
avoided given the patient’s suspiciousness.
Culture-Specific Psychoses
The following are examples of psychotic disorders seen within certain cultures:
Psychotic Manifestation Culture
Koro Intense anxiety that the penis will recede into the body, Southeast Asia
possibly leading to death. (e.g., Singapore)
Amok Sudden unprovoked outbursts of violence, often followed Malaysia

by suicide.
Brain fag Headache, fatigue, eye pain, cognitive difficulties, and other Africa
somatic disturbances in male students.
Comparing Time Courses and Prognoses

of Psychotic Disorders
KEY FACT
Time Course
■■ < 1 month—brief psychotic disorder SchizophreniFORM = the FORMation of
■■ 1–6 months—schizophreniform disorder a schizophrenic, but not quite there (i.e.,
■■ > 6 months—schizophrenia < 6 months).
Prognosis from Best to Worst

Mood disorder with psychotic features > schizoaffective disorder > schizo-
phreniform disorder > schizophrenia.
Q ui c k a nd E a s y D is t in g uis h in g Fe at u r es
■■ Schizophrenia: Lifelong psychotic disorder.

■■ Schizophreniform: Schizophrenia for > 1 and < 6 months.
■■ Schizoaffective: Schizophrenia + mood disorder.
■■ Schizotypal (personality disorder): Paranoid, odd or magical beliefs,
eccentric, lack of friends, social anxiety. Criteria for overt psychosis are
not met.
■■ Schizoid (personality disorder): Solitary activities, lack of enjoyment from
social interactions, no psychosis.
no t es
chapter 4
MOOD DISORDERS
Concepts in Mood Disorders 34 Specifiers for Depressive Disorders 39

Bereavement 40
Mood Disorders versus Mood Episodes 34
Bipolar I Disorder 40
Mood Episodes 34
Bipolar II Disorder 41
Major Depressive Episode (DSM-5 Criteria) 34
Specifiers for Bipolar Disorders 42
Manic Episode (DSM-5 Criteria) 34
Persistent Depressive Disorder (Dysthymia) 42
Hypomanic Episode 35
Cyclothymic Disorder 43
Differences between Manic and Hypomanic Episodes 35
Premenstrual Dysphoric Disorder 43
Mixed Features 35
Disruptive Mood Dysregulation Disorder (DMDD) 44
Mood Disorders 35 Other Disorders of Mood in DSM-5 45
Differential Diagnosis of Mood Disorders Due to Other Medical
Conditions 35
Substance/Medication-Induced Mood Disorders 36
Major Depressive Disorder (MDD) 36
33
34 chapter 4 MOOD DISORDERS
Concepts in Mood Disorders

A mood is a description of one’s internal emotional state. Both external and
WARDS TIP internal stimuli can trigger moods, which may be labeled as sad, happy, angry,
irritable, and so on. It is normal to have a wide range of moods and to have a
Major depressive episodes can be sense of control over one’s moods.
present in major depressive disorder,
persistent depressive disorder Patients with mood disorders (also called affective disorders) experience an
(dysthymia), or bipolar I/II disorder. abnormal range of moods and lose some level of control over them. Distress
may be caused by the severity of their moods and the resulting impairment in
social and occupational functioning.
Mood Disorders versus Mood Episodes

WARDS TIP
■■ Mood episodes are distinct periods of time in which some abnormal
When patients have delusions and mood is present. They include depression, mania, and hypomania.
hallucinations due to underlying ■■ Mood disorders are defined by their patterns of mood episodes. They
mood disorders, they are usually mood include major depressive disorder (MDD), bipolar I disorder, bipolar II
congruent. For example, depression disorder, persistent depressive disorder, and cyclothymic disorder. Some
causes psychotic themes of paranoia may have psychotic features (delusions or hallucinations).
and worthlessness, and mania causes
psychotic themes of grandiosity and
invincibility.
Mood Episodes
MA JOR DEPRESSIVE EPISODE (DSM-5 CRITERIA)
Must have at least five of the following symptoms (must include either num-
ber 1 or 2) for at least a 2-week period:
KEY FACT 1. Depressed mood most of the time
2. Anhedonia (loss of interest in pleasurable activities)
Symptoms of major depression— 3. Change in appetite or weight (↑ or ↓)
SIG E. CAPS (Prescribe Energy Capsules) 4. Feelings of worthlessness or excessive guilt
Sleep 5. Insomnia or hypersomnia
Interest 6. Diminished concentration
Guilt 7. Psychomotor agitation or retardation (i.e., restlessness or slowness)
Energy 8. Fatigue or loss of energy
Concentration 9. Recurrent thoughts of death or suicide
Appetite
Symptoms are not attributable to the effects of a substance (drug or medica-
Psychomotor activity
tion) or another medical condition, and they must cause clinically significant
Suicidal ideation
distress or social/occupational impairment.
MANIC EPISODE (DSM-5 CRITERIA)
A distinct period of abnormally and persistently elevated, expansive, or irrita-

WARDS TIP
ble mood, and abnormally and persistently increased goal-directed activity or
energy, lasting at least 1 week (or any duration if hospitalization is necessary),
A manic episode is a psychiatric
and including at least three of the following (four if mood is only irritable):
emergency; severely impaired
judgment can make a patient 1. Distractibility
dangerous to self and others. 2. Inflated self-esteem or grandiosity
3. ↑ in goal-directed activity (socially, at work, or sexually) or psychomotor
agitation
MOOD DISORDERS chapter 4 35
4. ↓ need for sleep

5. Flight of ideas or racing thoughts KEY FACT
6. More talkative than usual or pressured speech (rapid and uninterruptible)
7. Excessive involvement in pleasurable activities that have a high risk of Symptoms of mania—
negative consequences (e.g., shopping sprees, sexual indiscretions) DIG FAST
Distractibility
Symptoms are not attributable to the effects of a substance (drug or medica- Insomnia/Impulsive behavior
tion) or another medical condition, and they must cause clinically signifi- Grandiosity
cant distress or social/occupational impairment. Greater than 50% of manic Flight of ideas/Racing thoughts
patients have psychotic symptoms. Activity/Agitation
Speech (pressured)
HYPOMANIC EPISODE Thoughtlessness
A hypomanic episode is a distinct period of abnormally and persistently

elevated, expansive, or irritable mood, and abnormally and persistently
increased goal-directed activity or energy, lasting at least 4 consecutive days,
that includes at least three of the symptoms listed for the manic episode cri-
teria (four if mood is only irritable). There are significant differences between WARDS TIP
mania and hypomania (see below).
Irritability is often the predominant
mood state in mood disorders with
DIFFERENCES BETWEEN MANIC AND HYPOMANIC EPISODES mixed features. Patients with mixed
features have a poorer response to
Mania Hypomania lithium. Anticonvulsants such as
valproic acid may be more helpful.
Lasts at least 7 days Lasts at least 4 days
Causes severe impairment in social No marked impairment in social
or occupational functioning or occupational functioning
May necessitate hospitalization to Does not require hospitalization
prevent harm to self or others No psychotic features
May have psychotic features
M I X E D F E AT U R E S
Criteria are met for a manic or hypomanic episode and at least three symp-
toms of a major depressive episode are present for the majority of the time.
These criteria must be present nearly every day for at least 1 week.
Mood Disorders
Mood disorders often have chronic courses that are marked by relapses with
relatively normal functioning between episodes. Like most psychiatric diagno-
ses, mood episodes may be caused by another medical condition or drug (pre-
scribed or illicit); therefore, always investigate medical or substance-induced
causes (see below) before making a primary psychiatric diagnosis.
DIFFERENTIAL DIAGNOSIS OF MOOD DISORDERS DUE TO OTHER MEDIC AL

CONDITIONS
Medical Causes of a Depressive Medical Causes of a Manic
Episode Episode
Cerebrovascular disease (stroke, Metabolic (hyperthyroidism)

myocardial infarction) Neurological disorders
Endocrinopathies (diabetes mellitus, (temporal lobe seizures,
Cushing syndrome, Addison disease, multiple sclerosis)
hypoglycemia, Neoplasms
hyper/hypothyroidism, HIV infection
hyper/hypocalcemia)
Parkinson’s disease
Viral illnesses (e.g., mononucleosis)
Carcinoid syndrome
Cancer (especially lymphoma and
pancreatic carcinoma)
Collagen vascular disease (e.g.,
systemic lupus erythematosus)
S U B S TA N C E / M E D I C AT I O N - I N D U C E D M O O D D I S O R D E R S
Substance/Medication-Induced Subst ance/Medication-Induced

Depressive Disorder Bipolar Disorder
EtOH Antidepressants
Antihypertensives Sympathomimetics
Barbiturates Dopamine
KEY FACT Corticosteroids Corticosteroids
Levodopa Levodopa
Stroke patients are at a significant risk Sedative-hypnotics Bronchodilators
for developing depression, and this Anticonvulsants Cocaine
is associated with a poorer outcome Antipsychotics Amphetamines
overall. Diuretics
Sulfonamides
Withdrawal from
stimulants (e.g., cocaine,
amphetamines)
KEY FACT M ajor D epressive D isorder ( M D D )
Major depressive disorder is the most MDD is marked by episodes of depressed mood associated with loss of inter-
common disorder among those who est in daily activities. Patients may not acknowledge their depressed mood or
complete suicide. may express vague, somatic complaints (fatigue, headache, abdominal pain,
muscle tension, etc.).

■■ At least one major depressive episode (see above).
■■ No history of manic or hypomanic episode.
KEY FACT
Epidemiology
Most adults with depression do not
see a mental health professional, but
■■ Lifetime prevalence: 12% worldwide.
they often present to a primary care
■■ Onset at any age, but the age of onset peaks in the 20s.
physician for other reasons.
■■ 1.5–2 times as prevalent in women than men during reproductive years.
■■ No ethnic or socioeconomic differences.
■■ Lifetime prevalence in the elderly: <10%.
■■ Depression can ↑ mortality for patients with other comorbidities such as
diabetes, stroke, and cardiovascular disease.
KEY FACT
Sleep Problems Associated with MDD
Anhedonia is the inability to experience
■■ Multiple awakenings.
pleasure, which is a common finding in
■■ Initial and terminal insomnia (hard to fall asleep and early morning
depression.
awakenings).
■■ Hypersomnia (excessive sleepiness) is less common.
■■ Rapid eye movement (REM) sleep shifted earlier in the night and for a
greater duration, with reduced stages 3 and 4 (slow wave) sleep.
Etiology
WARDS TIP
The precise cause of depression is unknown, but MDD is believed to be a
heterogeneous disease, with biological, genetic, environmental, and psychoso- The two most common types of sleep
cial factors contributing. disturbances associated with MDD
■■ MDD is likely caused by neurotransmitter abnormalities in the brain. are difficulty falling asleep and early
Evidence for this is the following: antidepressants exert their therapeutic effect morning awakenings.
by increasing catecholamines; ↓ cerebrospinal fluid (CSF) levels of 5-hydroxy-
indolacetic acid (5-HIAA), the main metabolite of serotonin, have been found
in depressed patients with impulsive and suicidal behavior.
■■ Increased sensitivity of beta-adrenergic receptors in the brain has also been KEY FACT
postulated in the pathogenesis of MDD.
■■ High cortisol: Hyperactivity of hypothalamic-pituitary-adrenal axis, as shown The Hamilton Depression Rating Scale
by failure to suppress cortisol levels in the dexamethasone suppression test. measures the severity of depression
■■ Abnormal thyroid axis: Thyroid disorders are associated with depressive and is used in research to assess the
symptoms. effectiveness of therapies. PHQ-9 is a
■■ Gamma-aminobutyric acid (GABA), glutamate, and endogenous opiates depression screening form often used
may additionally have a role. in the primary care setting.
■■ Psychosocial/life events: Multiple adverse childhood experiences are a
risk factor for later developing MDD.
■■ Genetics: First-degree relatives are two to four times more likely to have
MDD. Concordance rate for monozygotic twins is <40%, and 10–20% for
dizygotic twins. KEY FACT
Course and Prognosis Loss of a parent before age 11 is

associated with the later development
■■ Untreated, depressive episodes are self-limiting but last from 6 to 12
of major depression.
months. Generally, episodes occur more frequently as the disorder pro-
gresses. The risk of a subsequent major depressive episode is 50–60%
within the first 2 years after the first episode. 2–12% of patients with MDD
eventually commit suicide. KEY FACT
■■ Approximately 60% of patients show a significant response to antidepres-
sants. Combined treatment with both an antidepressant and psychother- Depression is common in patients with
apy produce a significantly ↑ response for MDD. pancreatic cancer.
Treatment
Hospitalization
KEY FACT
■■ Indicated if patient is at risk for suicide, homicide, or is unable to care for
him/herself.
Only half of patients with MDD receive
Pharmacotherapy treatment.
■■ Antidepressant medications:
■■ Selective serotonin reuptake inhibitors (SSRIs): Safer and better toler-
ated than other classes of antidepressants; side effects are mild but
include headache, gastrointestinal disturbance, sexual dysfunction, and KEY FACT
rebound anxiety. Medications that also have activation of other neu-
rotransmitters include serotonin-norepinephrine reuptake inhibitors All antidepressant medications are
venlafaxine (Effexor) and duloxetine (Cymbalta), the α2-adrenergic equally effective but differ in side-effect
receptor antagonist mirtazapine (Remeron), and the dopamine-norepi- profiles. Medications usually take 4–6
nephrine reuptake inhibitor bupropion (Wellbutrin). weeks to fully work.
■■ Tricyclic antidepressants (TCAs): Most lethal in overdose due to cardiac
arrhythmias; side effects include sedation, weight gain, orthostatic hypoten-

sion, and anticholinergic effects. Can aggravate prolonged QTc syndrome.
■■ Monoamine oxidase inhibitors (MAOIs): Older medications occa-
sionally used for refractory depression; risk of hypertensive crisis when

used with sympathomimetics or ingestion of tyramine-rich foods, such
as wine, beer, aged cheeses, liver, and smoked meats (tyramine is an
intermediate in the conversion of tyrosine to norepinephrine); risk of
serotonin syndrome when used in combination with SSRIs. Most com-

WARDS TIP mon side effect is orthostatic hypotension.
Serotonin syndrome is marked by ■■ Adjunct medications:
autonomic instability, hyperthermia, ■■ Atypical (second-generation) antipsychotics along with antidepressants
hyperreflexia (including myoclonus), are first-line treatment in patients with MDD with psychotic features.
and seizures. Coma or death may result. In addition, they may also be prescribed in patients with treatment
resistant/refractory MDD without psychotic features.
■■ Triiodothyronine (T ), levothyroxine (T ), and lithium have demon-
3 4
strated some benefit when augmenting antidepressants in treatment
refractory MDD.
■■ While stimulants (such as methylphenidate) may be used in certain
WARDS TIP
patients (e.g., terminally ill), the efficacy is limited and trials are small.
Adjunctive treatment is usually Psychotherapy
performed after multiple first-line ■■ Cognitive-behavioral therapy (CBT), interpersonal psychotherapy, sup-
treatment failures. portive therapy, psychodynamic psychotherapy, problem-solving therapy,
and family/couples therapy have all demonstrated some benefit in treating
MDD (primarily CBT or interpersonal psychotherapy).
■■ May be used alone or in conjunction with pharmacotherapy.
Electroconvulsive Therapy (ECT)

■■ Indicated if patient is unresponsive to pharmacotherapy, if patient can-
KEY FACT not tolerate pharmacotherapy (pregnancy, etc.), or if rapid reduction
of symptoms is desired (e.g., immediate suicide risk, refusal to eat/drink,
Postpartum period conveys an elevated catatonia).
risk of depression in women. ■■ ECT is extremely safe (primary risk is from anesthesia) and may be used
alone or in combination with pharmacotherapy.

■■ ECT is often performed by premedication with atropine, followed by gen-
eral anesthesia (usually with methohexital) and administration of a muscle

relaxant (typically succinylcholine). A generalized seizure is then induced
WARDS TIP by passing a current of electricity across the brain (generally bilateral, less
commonly unilateral); the seizure should last between 30 and 60 seconds,
MAOIs were considered particularly
and no longer than 90 seconds.
■■ 6–12 (average of 7) treatments are administered over a 2- to 3-week period,
useful in the treatment of “atypical”
depression; however, SSRIs remain
but significant improvement is sometimes noted after the first treatment.
■■ Retrograde and anterograde amnesia are common side effects, which usu-
first-line treatment for major depressive
episodes with atypical features.
ally resolve within 6 months.
■■ Other common but transient side effects: Headache, nausea, muscle
soreness.
Ms. Cruz is a 28-year-old sales clerk who arrives at your outpatient

clinic complaining of sadness after her boyfriend of 6 months ended
their relationship 1 month ago. She describes a history of failed roman-
tic relationships, and says, “I don’t do well with breakups.” Ms. Cruz
reports that, although she has no prior psychiatric treatment, she was
urged by her employer to seek therapy. Ms. Cruz has arrived late to work
on several occasions because of oversleeping. She also has difficulty in
getting out of bed stating, “It’s difficult to walk; it’s like my legs weigh a
ton.” She feels fatigued during the day despite spending over 12 hours in
bed, and is concerned that she might be suffering from a serious medical
condition. She denies any significant changes in appetite or weight since
these symptoms began.
Ms. Cruz reports that, although she has not missed workdays, she has
difficulty concentrating and has become tearful in front of clients while
worrying about not finding a significant other. She feels tremendous

guilt over “not being good enough to get married,” and says that her
close friends are concerned because she has been spending her week-
ends in bed and not answering their calls. Although during your evalu-
ation Ms. Cruz appeared tearful, she brightened up when talking about
her newborn nephew and her plans of visiting a college friend next sum-
mer. Ms. Cruz denied suicidal ideation.
What is Ms. Cruz’s diagnosis?

Ms. Cruz’s diagnosis is major depressive disorder with atypical features.
She complains of sadness, fatigue, poor concentration, hypersomnia,
feelings of guilt, anhedonia, and impairment in her social and occupa-
tional functioning. The atypical features specifier is given in this case
as she exhibited mood reactivity (mood brightens in response to posi-
tive events) when talking about her nephew and visiting her friend, and
complained of a heavy feeling in her legs (leaden paralysis) and hyper-
somnia. It is also important to explore Ms. Cruz’s history of “not doing
well with breakups,” as this could be indicative of a long pattern of
interpersonal rejection sensitivity. Although it is common for patients
who suffer from atypical depression to report an ↑ in appetite, Ms. Cruz
exhibits enough symptoms to fulfill atypical features criteria. Adjustment
disorder should also be considered in the differential diagnosis.
What would be your pharmacological recommendation?

Ms. Cruz should be treated with an antidepressant medication. While
MAOIs such as phenelzine had traditionally been superior to TCAs in
the treatment of MDD with atypical features, SSRIs would be the first-
line treatment. The combination of pharmacotherapy and psychother-
apy has been shown to be more effective for treating mild-to-moderate
MDD than either treatment alone.
S pecifiers for D epressive D isorders
■■ Melancholic features: Present in approximately 25–30% of patients with

MDE and more likely in severely ill inpatients, including those with psy-
chotic features. Characterized by anhedonia, early morning awakenings,
depression worse in the morning, psychomotor disturbance, excessive
guilt, and anorexia. For example, you may diagnose major depressive disor-
der with melancholic features.
■■ Atypical features: Characterized by hypersomnia, hyperphagia, reactive
mood, leaden paralysis, and hypersensitivity to interpersonal rejection.
■■ Mixed features: Manic/hypomanic symptoms present during the majority
of days during MDE: elevated mood, grandiosity, talkativeness/pressured
speech, flight of ideas/racing thoughts, increased energy/goal-directed
activity, excessive involvement in dangerous activities, and decreased need
for sleep.
■■ Catatonia: Features include catalepsy (immobility), purposeless motor
activity, extreme negativism or mutism, bizarre postures, and echolalia.
Especially responsive to ECT. (May also be applied to bipolar disorder.)
■■ Psychotic features: Characterized by the presence of delusions and/or hal-
lucinations. Present in 24–53% of older, hospitalized patients with MDD.
Another random document with
no related content on Scribd:
infere-se com facilidade que extraordinaria força taes medidas
dariam á nova clientella cabralista.
Procedia o ministro movido apenas pela ambição pessoal de se
consolidar, fomentando-a? Não o acreditemos, porque, para além
d’esta consequencia, taes factos teem maior alcance. Pois não era
verdade, confessada, reconhecida por todos, a incapacidade do
povo, e o mallogro das experiencias democraticas e localistas? Que
havia pois a fazer, de que recurso lançar mão: senão centralisar o
poder, chamar o governo a uma minoria consistente e forte;
deixando de pé, para não aggravar questões, todas as fórmulas que
podendo ser viciadas não prejudicassem o plano? Encerrado um
circulo da sua existencia, o liberalismo vinha caír n’uma oligarchia
de facto, revestida de fórmulas e garantias ficticias. Na Hespanha e
em França acontecia outro tanto; e lá e cá, depois das reacções que
o absolutismo novo, illustrado, provocou, o liberalismo cedeu o lugar
ao scepticismo politico mais ou menos cesarista do imperio francez,
e da Regeneração portugueza.
Conhecemos, pois, nos seus traços essenciaes, o novissimo
systema, e como não póde haver politica sem uma base de
elementos e forças positivas a que se apoie, resta-nos saber quaes
eram as do cabralismo. No decurso do nosso estudo achámos duas
já: a aristocracia nova do propriedade e da finança, e a burocracia.
Mas estes dois elementos, preponderantes e decisivos na paz, não
bastavam para resistir á força material das numerosas plebes
agitadas pela democracia setembrista. O governo, desarmando e
dissolvendo as guardas nacionaes, eliminára a melhor arma de que
ellas dispunham nas cidades; mas restavam os campos, com os
habitos de guerrilha, enraizados por annos de guerra e anarchia.
Contra esses tinha o governo o exercito: porque todos os
commandos estavam nas mãos de generaes fieis e a officialidade
fôra depurada.
A restauração consummada por uma porção de tropa, tinha, de
facto, nos soldados o mais firme apoio, porque a adhesão decidida
do throno valia menos em uma nação a que per vim se impozera
uma dynastia nova, discutida desde a origem e atacada,
escarnecida, humilhada muitas vezes. A rainha era, comtudo, o
primeiro funccionario da nação, e não valia mais nem menos do que
a burocracia toda, com a qual se inscrevera na nova clientella
cabralista. Se lhe não succedeu como a Luis-Philippe, ou a Isabel ii,
caír com o systema, foi porque a Hespanha, a Inglaterra e as França
vieram juntas defendel-a em 47.
Burocracia, riqueza, exercito: eis os tres pontos de apoio da
doutrina; centralisação, oligarchia: eis o seu processo; mas nem as
fórmas nem as forças bastam para constituir um systema: são
apenas consequencias subsidiarias d’elle. Que era, no fundo, a
idéa? Seria o racionalismo espiritualista do seculo xviii que prégava,
contra o catholicismo, pela bocca da maçonaria, uma religião nova?
Não; a doutrina reconhecia o catholicismo, lavrára já a sua
concordata com Roma, e via nos padres excellentes instrumentos
de governo. A maçonaria perdera havia muito o caracter
revolucionario, e a revolução perdera tambem as ambições
religiosas. Como os casulos do bombyx ficam depois que a
borboleta voou, assim ficavam as lojas, rede de sociedades secretas
subsidiarias das sociedades politicas visiveis, a que o segredo e o
mysterio, porém, seductores dos simples, augmentavam até certo
ponto a força. Costa-Cabral afeiçoara tambem essa machina ao
serviço dos seus designios e ambições.
Se elle se propunha defender os ricos para consolidar a ordem, á

maneira do religioso Guizot, ou se, menos idealista nas suas vistas,
queria a ordem apenas como instrumento de enriquecimento do
paiz, é o que nos não sentimos habilitados a dizer; pensando,
comtudo, mais provavel a segunda hypothese. Como quer que seja,
era por esta que a sociedade opinava, já começada a converter ao
materialismo, sob a primeira fórma com que elle modernamente
appareceu; era para o materialismo pratico que a sociedade,
desilludida das chimeras liberaes, começava a pender.
Isso a que depois veiu a chamar-se melhoramentos-materiaes,
isto é, a construcção das obras publicas e o fomento da riqueza, eis
o que nós vemos como essencia do novo cartismo. A do antigo,
sabemol-o bem, fôra aristocratica. E, singular energia da realidade!
Costa Cabral, o percursor da nova edade portugueza, veiu a ser a
victima da Regeneração que, por outras palavras e com outros
meios, havia de executar-lhe o programma. A antiga educação
jurista e liberal do ex-tribuno dos Camillos compromettia com
doutrinas um movimento que, para vingar, exigia apenas
scepticismo: assim em França, tambem acontecia a Guizot, e os
regeneradores foram o nosso Segundo Imperio.
Mas, além d’estes defeitos de educação, o plano do Costa-Cabral
falhava por outro lado. José da Silva Carvalho antes, Fontes depois,
comprehenderam que a melhor finança para um paiz exhausto era
importar do fóra o dinheiro. Costa-Cabral, seguindo n’este ponto os
erros setembristas, pensou que os numeros, calculos e operações
phantasticas dos agiotas bastavam para inventar uma riqueza que
não existia. D’ahi veiu uma banca-rota precipitar a ruina do systema,
batido tambem por outros inimigos.
Costa-Cabral foi o iniciador dos caminhos-de-ferro, principal
instrumento com que depois se operou a restauração da riqueza
nacional; e a sua idéa de construir uma linha entre o Porto e Lisboa
e outra de Lisboa a Badajoz era considerada pelos politicos da
opposição a doidice de um vidente. O conde de Lavradio, na
camara, (Sess. de 3 de fevereiro 1846) assegurava que entre Lisboa
e Porto não haveria, ao anno, mais de seis mil passageiros; e
Cabral perguntava-lhe: «E se forem trezentos mil?—Isso não é
possivel, porque não ha no paiz viajantes para tanto movimento».
Qual dos dois via mais claro no futuro? Os caminhos-de-ferro
rematariam o systema de estradas macadamisadas, contratadas
com a companhia das obras-publicas; e regularisada a questão do
Thesouro—hoc opus!—estaria completo o programma da
regeneração economica do paiz.
O estadista que com tamanha audacia e tão variadas artes
pretendia chamar á industria uma nação que fôra desde seculos o
emporio ou a dependencia de um systema colonial, agora
abandonado e caduco na parte que se não perdera, esquecia que
no reino extenuado e doente, costumado á protecção e á preguiça,
não havia os capitaes moveis necessarios para realisar as obras
projectadas. Havia, sim, grossas quantias dispersas e infructiferas;
mas a maxima parte d’ellas, ou a parte de que o Estado podia dispôr
sem ir atacar a propriedade individual, pertencia ainda ás
corporações de mão-morta que tinham escapado ao cutello liberal:
ás misericordias e confrarias, instituições religiosas de beneficencia,
cujos fundos o povo não estava ainda costumado a vêr mobilisar.
Fazel-o, parecia um roubo. E o governo, atrevendo-se a tanto, e
propondo ao mesmo tempo augmentos de impostos, tornava facil
aos seus inimigos um ataque apoiado em instinctos de populações
vexadas já por uma administração oppressora.
Não está porém n’isso a causa particular da ruina do edificio
cabralista, mas sim na essencia do seu plano de restauração da
riqueza nacional. Implantando entre nós o systema seguido lá por
fóra de enfeodar os serviços publicos a companhias de
especuladores, o cabralismo obedecia no principio da sua formação:
era uma clientela dos ricos. Confiando a aventureiros o encargo de
realisar o plano das obras-publicas, o governo chamava em seu
auxilio a intervenção da agiotagem. Isto não era original, nem
particularmente nosso: tambem Guizot dizia aos seus: enrichessez-
vous! Mas uma nação como Portugal, ainda commovida pelos odios
pessoaes e partidarios, demasiadamente afastada da Europa
central, quer geographica, quer economica, quer scientifica e
religiosamente, para ter solidariedade com ella, nem podia contar
com a paz indispensavel ás regenerações economicas, nem esperar
que os capitaes europeus viessem encher os cofres das
companhias de agiotas portuguezes. Nem a formação de
companhias estrangeiras, nem a importação de muito dinheiro por
emprestimos successivos, eram possiveis ainda, como depois o
foram; e sem elles as combinações eram chimeras.
D’ahi resultou que as companhias, formadas apenas com os
recursos de que a nação dispunha, não viram o ouro a authorisar os
numeros; e mirradas, seccas, encastellando algarismos e trapaças,
sem conseguirem bater moeda, voltavam-se implorantes para o
governo que as creara com o fim de o auxiliarem a elle. E,
entretanto, vencidas por fas ou por nefas, as eleições de 45, o
governo apparece como triumphador, patenteando um plano largo e
vasto de administração e fomento. (V. Diario de 2 de janeiro, 46)
Tres annos de paz e trabalho haviam permittido já desembaraçar o
terreno dos obstaculos praticos; e organisados os serviços, cumpria
realisar o pensamento. A divida externa converter-se-hia n’um typo
unico de 4 por cento, equilibrava-se o orçamento, e a companhia
das Obras-publicas apparecia para restaurar a viação d’onde viria a
fortuna ulterior. Havia esperança e fé. O 5 por cento estava a 70; o 4
a 57; e as companhias (Confiança, banco, etc.) solidariamente
ligadas á situação cartista, viam na conservação do governo e na
victoria do seu systema futuros de riquezas douradas. Nunca a
emissão do banco fôra tão longe: passava de 9:000 contos.
Mas a victoria politica do governo dava lugar a uma derrota do
systema, como veremos; a prosperidade do edificio financeiro
encobria mal a sua falta de alicerce. Um vento de desordem que
soprasse, e ficaria feito em pó. Era um amalgama de supposições
de valores, tendo como realidade unica um vasio absoluto. As
companhias pediam a protecção do Thesouro; e o Thesouro
sacava-lhes todo o dinheiro disponivel, para com elle poder
apparentar abundancia. 5:000 contos se deviam ao banco; 6:000 á
Confiança. E como não havia dinheiro e só esperanças; e como as
companhias não passavam afinal de agentes do governo, ao qual
iam entregar fielmente o pouco que obtinham; e como o governo
não poderia, ainda que o quizesse, encobrir as fraudes, os roubos,
dos agiotas cujo representante era—o systema alluia-se por todos
os lados, quando parecia ter chegado á sua perfeição.
Bastou uma revolução para deitar por terra os castellos de cartas
dos Laws cabralistas; mas houve fomes e sangue derramado,
porque a doutrina não tinha outra base além do ouro e o ferro.
Agiotas e soldados a defendiam; acabou com uma guerra e uma
falcatrua.
A sua grande falta, a sua fraqueza invencivel eram a ausencia de

um principio moral, porque nem a ordem imposta pela força, nem a
riqueza creada contra a justiça chegam a ser principios; nem o é a
idéa de que uma nação obedeça ao pensamento exclusivo de se
enriquecer. Quando isto se préga, succedem casos analogos aos
que succederam aos jesuitas: pervertem-se os ouvintes e logo se
corrompem os prégadores. Ou se criam monstros, como as missões
do Brazil e do Paraguay[27] e as companhias cabralinas, ou se cáe
na profunda atonia portugueza do seculo xviii ou na singular, chatin
regeneração.
Enriquecer é bom, indispensavel até; mas a riqueza é um meio e
não um fim.[28] Errando n’este ponto, dando á força bruta um papel
excessivo, confiando de mais no entorpecimento do povo e na
fraqueza dos inimigos: o cabralismo tinha na sua doutrina a causa
fatal da sua ruina, e o motivo necessario dos erros e do descredito
de chefes que precipitaram a queda inevitavel do systema.
Levantavam-se contra homens e systema elementos de varias
ordens: era a repugnancia instinctiva do caracter setembrista pelas
trapaças agiotas, eram os odios pessoaes, eram as resistencias do
povo contra os ataques a restos de instituições historicas e
costumes religiosos, era o bandidismo guerrilheiro fervendo por
voltar a uma existencia de aventuras, era a tradição democratica do
setembrismo que se não convertera, eram a resistencia e o protesto
contra a tyrannia da administração e as violencias das eleições, era
finalmente a existencia de numerosos officiaes expulsos das fileiras
por opiniões politicas.
Eis os elementos positivos da reacção que vamos vêr erguerem-
se, para condemnar a ultima tentativa de liberalismo doutrinario;
para lançar ao ostracismo o seu defensor; para concluir por fim o
periodo propriamente liberal, abrindo uma éra nova de scepticismo
politico, em que o velho idolo da liberdade, apeiado, cede o altar
ao deus novo: o utilitarismo, pratico, positivo, conciliador e moderno,
ou antes, actual.
NOTAS DE RODAPÉ:
[26] V. O Brazil e as colon. port. l. ii, 1.

[27] V. O Brazil e as colon. port. I, 4-5.
[28] V. O Regime das Riquezas, introd.
II
A REACÇÃO
1.—A COALISÃO DOS PARTIDOS
No decreto (10 de fevereiro) em que a rainha declarara adherir á

revolta armada em Coimbra dizia-se que a carta seria reformada,
mas logo que o gabinete se constituiu, quinze dias depois, com
Costa-Cabral, viu-se que a promessa ficava em cousa nenhuma: era
a carta, tal qual existia antes de 1836; pares hereditarios, eleições
indirectas. Mousinho d’Albuquerque, reconhecendo que apenas
passára pelo governo para preparar a entrada de Costa-Cabral,
abandonava o seu duque e collocava-se em opposição.
Ia haver eleições, porque o novo systema não era nem pretendia
ser uma dictadura, mas apenas a maneira de fundar uma legalidade
que servisse de escudo a um absolutismo de facto. E na vespera
d’essas eleições ligaram-se todas as clientelas ou partidos contra o
inimigo declaradamente commum. Eram os velhos setembristas da
gemma, com a geração nova ainda mais radical; eram os ordeiros,
antigos cartistas, expulsos do poder; eram cartistas não cabralistas,
e por fim miguelistas. No seio do constitucionalismo via-se
exactamente o mesmo que a Edade-media, com o seu feodalismo,
apresentára. A sociedade, dividida em bandos rivaes o inimigos
unidos em volta de um chefe, existia á mercê dos pactos, allianças e
rivalidade dos barões. Contra o feliz, vencedor temporario, eram
todos alliados, para se formarem combinações novas, assim que o
ramo da victoria passasse a mãos diversas. Nos seculos passados,
comtudo, não havia as mais das vezes por motivo declarado senão
a ambição pessoal, ainda que não fosse raro vêr-se, como agora,
servirem principios de capa aos despeitos e interesses. Nos seculos
passados, os debates eram campanhas, e agora pretendia-se que
fossem comicios e discussões e votos; mas como isso não bastava
muitas vezes, logo se appellava para a ultima ratio, a revolta.
A coalisão dos partidos preparou a batalha das eleições com um
Manifesto (30 de março de 42): «Haverá um simulacro de
representação nacional, dizia. A universalidade da nação
portugueza, fraccionada pelas diversas opiniões politicas, verá
passar pelo meio d’ella um bando pequeno de homens compactos e
ligados por seus interesses pessoaes, e obter um falso triumpho,
devido não só á sua força, mas á divisão dos seus contrarios.» Mau
prenuncio para quem desenhava tão realistamente uma situação
que pretendia dominar. Como esperava a coalisão vencer, se o
disparatado das ambições congregadas obrigava a declarar a
independencia dos credos politicos, e se a alliança tinha por fim
unico a batalha? Se ganhasse a victoria, de quem seria o ramo?
Novas contendas surgiriam sem duvida, o com ellas o estado
anterior de desordem.
Costa-Cabral venceu, e devia ser assim. Quem o havia de matar
não podia ser a opposição, mas sim a desorganisação e o
descredito do seu novo e tambem ephemero liberalismo. Agora,
porém, começava apenas a viagem e tudo eram confianças e
esperanças. Havia adhesões numerosas, e trabalhava-se. Palmella,
convertido depois da sua triste entrudada, dava ceremoniosamente
a mão ao governo, e ia a Inglaterra negociar o novo tratado que
congraçaria de novo comnosco a nossa protectora, coarctando as
temeridades proteccionistas do setembrismo. Publicára-se o codigo
administrativo. (18 de março de 42) Reconstituia-se a ordem, por
dentro e por fóra; e confiava-se que tivesse chegado o momento de
pensar no futuro. Por isso se legislava sobre a Instrucção, se
levantava o theatro romantico, se projectavam estradas e pontes.
Tinham-se, porém, liberal, constitucionalmente, convencido os
colligados da adhesão do reino ao seu novo regime? Não, nunca:
pois que cada qual possuia uma verdadeira traducção de
liberdade, a questão era para todos radical, e viciosa qualquer
legalidade que não fosse a propria. O principio da anarchia
constitucional desvairava, assim, os simples, servindo os
programmas de capa aos habeis para esconderem os seus motivos
particulares. Batidos na urna, appellaram para a guerra. Uma lucta
desabrida de improperios, na camara em discursos e fóra d’ella nos
jornaes e folhetos avulso, preparava o terreno para a desejada
insurreição em armas.
A coalisão dizia que «Palmella, por mandado do vil e infame
governo, fôra negociar o tratado de commercio: por patriotismo, os
fabricantes deviam fechar durante quinze dias as suas officinas.»
(Circular de 9 de agosto) Duas semanas sem pão, ociosos nas ruas
os operarios de Lisboa, repetir-se-hiam as scenas de 38 e caíria o
governo. Planeava-se a revolta, a que Passos chamou
«bambochata». E, com effeito, era tal a desorganisação, que os
miguelistas começavam já a esperar e por isso a abster-se, vendo
circumstancias opportunas para se effectuar uma restauração
nacional.» (Circ. de Saraiva, 24 de junho de 43)
A revolta declarada ia precipitar o ministro no campo das
repressões violentas, forçando-o a desmascarar a sua legalidade
que, no fundo, era de facto a brutalidade da força; levando-o a
mostrar com franqueza o genio duro e secco, esse genio que em
outros tempos e com outra estabilidade de instituições, teria levado
os inimigos ao mesmo caes de Belem, onde Pombal conduziu os
que lhe resistiram.[29]
Como o ministro de D. José, tambem o novo Pombal do
constitucionalismo era abocanhado e discutido na sua honra. Não
era credor, ou affigurava-se a muitos não ser, do respeito com que
uma reputação limpa ampara a força. Era temido, mas nem era
venerado, nem chegava a ser tomado a sério pelos antigos
companheiros que o tinham conhecido humilde, esbaforido, a
declamar nos Camillos. Vêl-o assim erguido sobre todos,
desesperava os que, por lhe não terem ouvido phrases pomposas e
poeticas, lhe negavam um talento que para romanticos estava
principalmente no estylo e na imaginação. Não era admirado: pelo
contrario. E o peior era que a sua honestidade não deixava de ser
discutida. Valiam mais e iam mais fundo esses ataques, do que as
investidas declamatorias e os protestos contra a tyrannia. Á força de
as ouvir, os ouvidos estavam saciados d’esse genero de esgrima;
mas quando se dizia que o ministro se vendia, conciliavam-se todas
as attenções.
Usar do dinheiro como instrumento liberal fel-o do certo. «Dêem-
me dinheiro e deixem o resto por minha conta», parece que disséra
ao entrar no governo, nas vesperas das eleições de 42. (Costa
Cabral em relevo) E os seis contos—oh modestia spartana!—que
recebeu e gastou, foram o ponto de partida para as accusações da
venalidade. Vendera um pariato, dizia-se, recebendo como prenda
um palacete. Quem do Ultramar queria commendas, mandava o
pedido acompanhado por uma ordem de dois contos para um
banqueiro. (Ibid.) E sem duvida, á sombra do ministro que
governava com o dinheiro, formara-se um batalhão de gente,
especulando com tudo: contractos, empregos e graças. No norte do
reino parece que havia um intimo, outr’ora preso por falsario e
ladrão, a quem os pretendentes se dirigiam para resolver as
pendencias que tinham em Lisboa, discutindo-se, não o direito, mas
sim a quantia. (Ibid.)
A propagação de taes accusações mostrava o calcanhar do novo
Achilles. Quando todas as fontes de authoridade politica se
estancam, resta apenas a authoridade pessoal: e nada ha melhor,
para a destruir, do que o uso da arma acerada que fere um homem
com o labéo de venal. O povo crê sempre, porque é pessimista:
tinha Portugal motivos para ser outra cousa? E para destruir uma tal
crença, não raro illusoria, nem provas bastam. O politico é como a
mulher de Cesar: além de honrada, (quem sabe? até não o sendo) é
mister que o pareça.
O nosso ministro não conseguia parecel-o, e soffria as
consequencias do seu plano de governo: «Enriquecei!» era o
conselho se Guizot, a quem ninguem taxou de deshonesto. Em
Portugal, os costumes eram mais soltos, a virulencia maior; e se
ninguem fôra ainda atacado de um modo tão cruel, isso prova que
ninguem, tampouco, ainda mostrára uma força e um genio tão
superiores. Outro Pombal, repetimos, o novo ministro ficaria tão
celebre como o antigo, se achasse ainda de pé uma qualquer
authoridade social. Nas ruinas universaes não tinha com que
construir, e os elementos que iam rebellar-se contra elle obrigal-o-
hiam a empregar, francamente a força núa como instrumento de
conservação.
2.—TORRES NOVAS E ALMEIDA
O melhor d’essa força era a tropa, mas usar d’ella na defeza de

um governo e de um systema cuja origem era discutida, tornava
logo o exercito em instrumento partidario, roubando-lhe esse
caracter mudo e passivo, sem o qual vem a ser um perigo
permanente. As condições da nossa historia, o abatimento caduco
do nosso povo, tinham feito com que, desde 20, as revoluções
portuguezas—sem excluir a de 32-4—fossem emprezas militares.
Os chefes de partido, Silveiras, Terceira, D. Pedro, Saldanha, Sá-da-
Bandeira, eram invariavelmente generaes; e agora, com Costa-
Cabral, pela primeira vez se via o governo positivo nas mãos de um
paisano, mas sob a presidencia de Terceira, com a adhesão de
Saldanha, marechaes do exercito.
Educado desde largos annos na tradição dos pronunciamentos, o
exercito era, portanto, como que uma prolação dos partidos: uma
parte, armada, das clientelas. Vê-se que desordem isto produziria. A
parcialidade vencedora dispunha em proveito proprio do material de
guerra: soldados, espingardas, canhões, etc., expulsando os
officiaes hostis para o quadro da inactividade, e mantendo, assim,
uma como que emigração dentro do reino, constantemente
preocupada de politica e tramando a victoria dos seus, a queda dos
contrarios. Com a exaltação de Costa-Cabral, as cousas tinham
chegado ao ponto de os coroneis pedirem aos officiaes
arregimentados palavra d’honra de se não bandearem; e os officiaes
davam-n’a e faltavam por dinheiro que recebiam, e quando a não
davam eram riscados do effectivo. (Apont. hist. cit.)
De tal situação nasceu a revolta de Torres-Novas, a que Passos-
Manuel chamou bambochata. Commandava ahi cavallaria 4 o
coronel Cesar de Vasconcellos, (depois feito conde do lugar da
façanha) que se pronunciou contra o governo (4 de fevereiro de 44),
e ao regimento foram juntar-se os militares inactivos. No dia
seguinte, Costa-Cabral pediu ás camaras a suppressão de garantias
e as leis marciaes, e obteve-se no meio dos clamores da opposição:
Mousinho d’Albuquerque, Aguiar, Gavião e Silva-Sanches, Garrett,
nos deputados; Lavradio, Taipa, Sá-da-Bandeira, Fonte-Arcada, nos
pares. Clamando, os opposicionistas encobriam mal, sob
expressões juridicas, a sua cumplicidade na sedição militar;
appellando em gritos violentos, exclamações dirigidas ás galerias,
para um motim popular.
Bomfim, o ordeiro antigo, pozera-se á frente da desordem, e a
praça de Almeida pronunciara-se tambem: ahi se achavam o
coronel Passos e José-Estevão que deixára a camara pelo campo.
(Oliveira, Esboço hist.) A coalisão dava de si uma revolta militar, e o
governo via os miguelistas a levantar a cabeça no meio da anarchia.
Beirão que viera á camara, eleito por elles, alliciava os estudantes
realistas em Coimbra, recrutando soldados para Almeida, d’onde lhe
escreviam que mandasse o Rebocho, para Minzella, agitar-se.
(Disc. de Cabral, 18 de outubro de 44) Para Almeida foram de
Torres-Novas as tropas, e sem poderem arrastar comsigo nenhuma
parte do paiz, acharam-se ahi encerradas em abril. O exercito fiel ao
governo cercava-as. Em vão saíu José-Estevão, romantica,
aventureiramente, a revolucionar Traz-os-Montes, passando a
fronteira e indo entrar em Moncorvo; em vão bateu ás portas de
Chaves, de Bragança e de Murça: ninguem respondeu; mas
ninguem tampouco entregou o estouvado romantico, pelo qual
Costa-Cabral offerecera, ao que se affirma, o premio de dois contos.
(Oliveira, Esboço hist.) Almeida capitulou, os vencidos emigraram, o
governo venceu; mas a victoria obrigava-o á crueldade e a derrota
exasperava os animos dos submettidos á tyrannia de um homem
que desprezavam.
Das ruinas da revolta renasceu mais firme a coalisão, para as

eleições de 45. Havia uma guerra declarada contra o governo, cujo
existencia era um incessante combate. Todos os chefes e clientelas
apertavam as mãos, esquecendo odios antigos no ardor do odio
novo contra o aventureiro que os batia a todos. O calor era tal que o
povo como que accordava, interessando-se e intervindo nos
debates dos politicos, emittindo opiniões e pareceres. «A mania
politica tem acommettido todos os habitantes da capital, desde o
fidalgo e o par do reino até ás fezes da plebe. Apenas os pobres
pretos de Africa que passeiam aos milhares pelas ruas de Lisboa
não discutem politica». (Lichnowsky, Record.) A rede de sociedades
secretas, que minavam o reino, estabelecia um sub-solo á politica
apparente. Costa-Cabral era chefe de uma maçonaria sua,
herdando o malhete que fôra de Silva-Carvalho e de Miranda: o
centro cartista. Saldanha perdera o posto supremo da maçonaria
opposta, desde que se bandeara em 35, deixando o grão-mestrado
a Manuel Passos, que dirigia tambem outros conventiculos:
templarios, vendas-carbonarias, etc. (Macedo, Traços)
A alliança das opposições já tinha um jornal, a Coalisão que,
francamente, accusava tanto o governo pela sua tyrannia, como o
povo pela sua indolencia.
Ha no paiz muito homem que não sabe lêr. Ha muito
homem que sabe lêr, mas não lê. Ha muito homem que lê,
mas não entende. Ha muito homem que lê e que entende,
mas que tem medo, que é vil como um porco e cobarde como
um veado. Ha muito homem que vê as desgraças publicas,
mas não as quer remediar; ou porque treme de susto, ou
porque ganha com a carrapata. Aos que vivem da sopa
gorda, da olha podrida do orçamento não ha que dizer ...
Folgam com as listas de côr, de carimbo e de tarja, morrem
pelas transparentes. Fingem que vão coactos, mas vão
contentes. Votam pela comezana: gostam da boa fatia do pão
do nosso compadre Povo.—Ó Costa-Cabral! quantas vezes
terás tu dito como Tiberio, vendo estes poltrões, estes
sanchopansas da liberdade: ó homines ad servitutem
paratos! (Coalisão, 10 de janeiro)
Mas este tom, de uma sinceridade triste, não era o que convinha
na vespera da batalha: «Á urna! á urna! abaixo todos os ladrões e
comedores! Empregados, ladrões, falsarios e prevaricadores, votae
com o governo: não vos queremos. Tratantes! pertenceis de corpo e
alma ao ministerio». (Coalisão, 15 de janeiro.)
Costa-Cabral ainda confiava, ainda esperava dominar a tormenta
que todos os dias crescia. Tinha o exercito, tinha a burocracia, via-
se apoiado pelas nações alliadas; o balão da finança entumescia-se,
e o proprio Tojal, da Fazenda, mettera tudo quanto tinha n’uma
operação de fundos, de sociedade com banqueiros de Londres. A
rainha entregara-se nas mãos do seu homem-novo, no qual via uma
coragem e uma força! ella que, se fosse homem, faria exactamente
o mesmo, ou mais ainda por ser monarcha.
O ministro plebeu não podia resistir ás tentações da vaidade
palaciana: não via que as honras com que a rainha o exalçava, o
diminuiam no espirito commum. A sinceridade democratica do povo
e a inveja dos ambiciosos juntavam-se para ridicularisar o parvenu.
A fortuna que juntára no poder, alvo de tantas accusações,
permitira-lhe comprar as terras de Thomar, com o velho castello
templario, onde o moderno burguez afidalgado, occupando as salas
historicas povoadas de sombras romanticas de cavalleiros, as
enchia de festas banaes por occasião da visita da sua liberal
soberana:
Na cathedral de Lisboa
Sinto sinos repicar:
Serão annos de princeza?
D’algum santo o festejar?
É a rainha que se parte
Té ás terras de Thomar.
..............................
Em vez das armas antigas
Dos nobres valentes Paes,
Na fachada, sobre o portico,
Vêem-se hoje as dos Cabraes
Que em seu campo ensanguentado
Por brazão tém tres punhaes.
(Xacara da visita da rainha, etc.)

O romantismo vingava-se, e as formulas da nova arte-poetica
mostravam servir para muito. Era um romance á imitação dos da
collecção de Garrett, e em que a mais desbragada calumnia não
perdoava a ninguem. Já não bastava a honra do ministro, exigia-se-
lhe a da esposa e a da propria rainha. Os dois casaes, o das
Necessidades e o de Thomar, viviam n’uma indecente
promiscuidade. A castellan dizia á rainha:
Mas não venhas tu sósinha

Traz tambem o teu esposo
Lá das terras d’Allemanha
Esse moço tão formoso,
De louros, finos, cabellos
Gentil, nobre, valoroso.
E ao castellão «todo vestido de gala—cinge-lhe a fronte a

armadura», ao mesmo tempo que «praticava mui de manso» com a
rainha «recostada em molle sophá.» Um temporal interrompe as
festas, e vem o mendigo-povo cantar a lenda que termina:
E o Senhor decretou
Exterminio á geração
Sobre essa raça maldita!
Assim, em artigos e trovas, se tirava a desforra de uma revolta

suffocada, infiltrando no animo do povo um desprezo e um odio
condemnadores do ministro e da rainha, do systema e das pessoas.
A colera politica subia de grau, e a liberdade na imprensa—tão
verberada por Passos!—invadia as alcovas principescas,
mostrando-as ás plebes. Onde conduziria um tal systema? Não
tinham os miguelistas razão para se prepararem e esperar?
Batidas por fim de frente, por um homem superior e forte que
lançára mão dos elementos ainda resistentes da sociedade
portugueza, as parcialidades politicas, relativamente tolerantes entre
si, não podiam admittir a invasão e o imperio d’esse intruso
importuno; mas elle proprio, que não se atrevia, nem poderia, nem
pensaria, em rasgar a carta, mandar á fava o liberalismo, e voltar
ao governo pessoal, puro: que lhe restava senão curvar a cabeça á
tyrannia das fórmulas? E se as influencias de todos os chefes
politicos, alliados contra elle; se a acção de um ataque incessante á
sua pessoa e á sua honra, tinham concitado uma tempestade que o
faria ser batido na urna: que remedio lhe restava, senão esse
expediente da violencia sob a capa de legalidade? o processo de
mentira descarada, em vez de hypocrita como d’antes? esse
processo que o mantinha, desacreditando-o, arruinando-o cada vez
mais?
Vencer, por fas ou por nefas, as eleições, n’esse anno de 45 da
decisiva batalha, era para Costa Cabral o mesmo que viver ou
morrer. Lançou, pois, mão de tudo, e foi ás do cabo. Tres camaras-
municipaes protestaram, vindo a Lisboa os vereadores implorar a
rainha: á de Evora voltou-lhe ella as costas, a de Villa-Franca foi
presa, e ambas, com a de Faro, dissolvidas. A opposição estava
inteira a postos; o programma era o antigo Manifesto da coalisão,
com o discurso de Manuel Passos, em 18 de outubro anterior. Em
Lisboa reuniam-se Mousinho de Albuquerque, Aguiar, Sá-da-
Bandeira, Herculano, José Maria Grande, Marreca, Rio-Maior,
Jervis, Garrett; José Passos tinha o Porto; Bertiandos, o Minho;
Povoas, não annuindo á abstenção ordenada por D. Miguel, da
Guarda mandava na Beira; o conde de Mello em Portalegre; Manuel
Passos e o barão de Almeirim em Santarem. (Macedo, Traços)
Nenhuma das conhecidas tricas para levar a Urna a dizer o que
se deseja—como nos velhos oraculos sagrados!—fôra esquecida
pelo governo. Os recenseamentos eram taes que não incluiam
nomes como os do marquez de Niza, da Fonte-Arcada, do
Felgueiras juiz no supremo tribunal, de Garrett, etc. Incluiam, porém,
mendigos e lacaios, aguadeiros e defunctos; incluiam nomes
imaginarios, e soldados e marinheiros. As listas eram marcadas:
transparentes, pautadas, carimbadas, tarjadas, numeradas. Os
individuos influentes e perigosos eram presos arbitrariamente: assim
aconteceu a Rezende em Aveiro, a Balsemão em Penafiel. Os
governadores-civis distribuiam aos galopins mandados de captura
em branco. E onde as tricas não bastavam, apparecia a força bruta.
Em Alvarães e Porto de Moz houve descargas cerradas de fusilaria.
D. João de Azevedo foi espancado no Porto, onde as assembleias
se reuniam cercadas de tropa, junto dos quarteis. O visconde da
Azenha teve de emigrar de Guimarães; o de Andaluz, em Pernes,
bateu a tropa com um bando de gente armada. Para Villa-Franca foi
maruja e artilheria. No Sardoal a tropa de bayoneta calada impediu
a entrada dos eleitores na assembleia. Por toda a parte houve
prisões, mortes em muitos lugares. A violencia vinha rematar o
systema de perseguições fiscaes: iniquidade na repartição do
imposto, crueldade com os devedores das misericordias e
irmandades, denegações de justiça, etc. (Macedo, Traços) Para
forjar um simulacro de parlamento, para aguentar a sophismação da
doutrina, chegava á maxima tyrannia, atacando-se as mais
necessarias garantias dos cidadãos.
Costa-Cabral venceu: se victoria se póde chamar a empreza que
o precipitou n’uma revolução.
No seio da sua camara unanime de clientes e funccionarios expoz
então o vasto plano dos seus projectos; mas na outra camara, os
pares protestavam clamorosos, erguendo-se acima de todas a voz
sibilante de Lavradio, e dominando a scena a figura de Palmella
que, moderado sempre, inclinava outra vez para o lado da
opposição.
Cá por fóra os protestos corriam soltos e sem piedade:
Que podemos nós esperar, quando a nossa vida, a nossa
fazenda, a nossa liberdade estão á mercê de um punhado de
devassos? Se esta nossa terra, se os nossos fóros e
liberdades são enphyteose dos Braganças ou fateosim dos
Cabraes? (Souto-Mayor, Cartas de Graccho a Tullia)
Os ministros são «doutores do pinhal d’Azambuja», que illudem a
nação com «tretas vís»; são «ladrões cadimos, salteadores,
assassinos, traficantes, ratoneiros, corsarios, bandoleiros»; e o povo
não ouve? não se mexe?
Povo! meneia tres vezes a cabeça, reflecte. Não tens um
pulso para a espada, um hombro onde encostes a
espingarda, olhos para a pontaria, dedos para o gatilho? (Id.
Ultimos adeus, 44)
3.—A MARIA-DA-FONTE
Accudiu o povo aos clamores dos que se apresentavam como

seus procuradores? Elles disseram que sim: á historia parece
comtudo que o povo era indifferente ás doutrinas e systemas da
opposição; porque nem ellas tornaram completamente a vencer,
nem o povo se levantou para as defender, quando a rainha por um
acto de absolutismo expulsou do governo os homens que ali tinham
entrado sob pretexto da Maria-da-Fonte. Como espontaneo
movimento das populações, a revolução do Minho tem apenas um
caracter negativo. É contra os Cabraes, de quem a propaganda
activa fizera uns monstros mais que humanos, que appareciam á
imaginação popular como réus de todas as desgraças:
Comem as cearas os pardaes?

É por culpa dos Cabraes.
É contra os impostos, contra os enterramentos em cemiterios ao

ar livre, contra a mobilisação dos bens das Misericordias, contra o
systema de leis que tendiam a consolidar o novo Portugal, a acabar
de arruinar um Portugal antigo que ainda para as populações ruraes
era o verdadeiro, o ditoso, o bom. Tal caracter se observa no
movimento espontaneo das populações, confiscado á nascença
pelos setembristas como se fôra seu, e apresentado sempre como
um documento da vitalidade e raizes das suas doutrinas no seio da
nação ...
Quando na camara dos pares os ataques sibilantes de Lavradio
ao conde de Thomar zuniam como o vento nas cordagens do navio
ameaçado; quando a eloquencia apopletica de José-Bernardo se
entornava para defender o irmão, ameaçando terra, mar e mundo;
quando a batalha parecia decisiva e final—chegou a Lisboa,
subitamente, a noticia de motins populares no Minho. (15 de abril) O
governo assustou-se e os inimigos esperaram.
Entre clamores e protestos, votaram-se as leis marciaes usadas
em taes casos, porque nos momentos de crise o constitucionalismo
liberal vê-se forçado a abdicar: tal é a sua consciencia positiva.
Suspenderam-se os debates para irem começar os tiros. A
opposição tinha organisado por todo o reino a sua machina eleitoral
coalisada: os embryões das Juntas revolucionarias estavam
formados, a postos todo o pessoal dos partidos, para accudir ao
levantamento das populações, dirigindo-o, interpretando-o. Por seu
lado o governo mandou para o Porto José-Cabral, a quem o odio da
cidade do Douro chamára o José dos Conegos, e agora dava por
escarneo o titulo de Rei-do-norte. Levava, com effeito, o rei poderes
descricionarios e a alma cheia de coleras, a bocca vomitando
ameaças, o braço levantado para esmagar tudo com a sua força. E
assim que desembarcou, passou dos planos ás obras, perseguindo,
prendendo, ameaçando, aterrorisando, até que o obrigaram a voltar,
fugindo para salvar a vida.
E a tropa? Mais que podia a tropa contra uma sublevação de facto
popular, levantando a cabeça por toda a parte, oscillando, fugaz, e
movediça, lavrando e minando, com a vastidão e mobilidade dos
fogos fatuos no vasto cemiterio de um reino? O governo não tinha
cem mil bayonetas, e tantas ou mais seriam necessarias para pôr
guarnição em todas as aldeias, uma sentinella ao lado de cada
minhoto. O caso era diverso de 44, quando uns batalhões se tinham
pronunciado: outros batalhões mais numerosos foram ter com elles,
encerraram-nos em Almeida, obrigando-os a capitular. Que praça ou
curral havia, sufficientemente grande para encerrar meia população
do reino e obrigal-a a render-se pela fome? Praça ou curral era o
reino inteiro, e dentro da fortaleza a propria guarnição levantava-se.
Que fazer? Onde accudir? A força ensarilhava as armas por não
achar alvo de pontaria; e do mesmo modo que a tropa reconhecia a
sua impotencia, via-se em Lisboa a manada dos agiotas correr,
sumir-se, apertados uns contra os outros, furando como os bandos
de carneiros acossados por um aguaceiro a trotar miudinho. Ai!

First Aid For The Psychiatry Clerkship Fourth Edition Latha Ganti Full Chapter

Uploaded by

Copyright:

Available Formats

You might also like

First Aid For The Psychiatry Clerkship Fourth Edition Latha Ganti Full Chapter

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

First Aid For The Psychiatry Clerkship Fourth Edition Latha Ganti Full Chapter

Uploaded by

Copyright:

Available Formats

First Aid for the Psychiatry Clerkship,

Fourth Edition Latha Ganti

Tips on what to know to IMPRESS

LATHA GANTI, MD, MS, MBA, FACEP Sean M. Blitzstein, MD

eBook conversion by codeMantra

Chapter 1: How to Succeed in the Psychiatry Clerkship 1

Chapter 2: Examination and Diagnosis 11

Chapter 3: Psychotic Disorders 21

Chapter 4: Mood Disorders 33

Chapter 5: Anxiety, Obsessive-Compulsive, Trauma, and Stressor-Related Disorders 47

Chapter 6: Personality Disorders 63

Chapter 7: Substance-Related and Addictive Disorders 79

Chapter 8: Neurocognitive Disorders 97

Chapter 9: Geriatric Psychiatry 113

Chapter 10: Psychiatric Disorders in Children 121

Chapter 11: Dissociative Disorders 133

Chapter 12: Somatic Symptom and Factitious Disorders 139

Chapter 13: Impulse Control Disorders 145

Chapter 14: Eating Disorders 151

Chapter 15: Sleep-Wake Disorders 159

Chapter 16: Sexual Dysfunctions and Paraphilic Disorders 171

Chapter 17: Psychotherapies 179

Chapter 18: Psychopharmacology 189

Chapter 19: Forensic Psychiatry 209

How to Succeed in the

Why Spend Time on Psychiatry? 2 Keep Patient Information Handy 3

How to Behave on the Wards 2 Present Patient Information in an Organized Manner 3

Why Spend Time on Psychiatry?

Being aware of and understanding the features of mental dysfunction in psy-

Psychotropic medications are frequently prescribed in the general popula-

Because of the unique opportunity to spend a great deal of time interacting

How to Behave on the Wards

Always maintain professionalism and show the patients respect. Be respectful

■■ Regardless of your interest in psychiatry, take the rotation seriously.

Be enthusiastic and self-motivated. Volunteer to help with a procedure or a

Use a clipboard, notebook, or index cards to keep patient information, includ-

Here is a template for the “bullet” presentation:

“This is a [age]-year-old [gender] with a history of [major history such

The newly admitted patient generally deserves a longer presentation following

How to Prepare for the Clerkship (Shelf ) Exam

Other helpful studying strategies include:

STUDY WITH FRIENDS

STUDY IN A BRIGHT ROOM

Mental Status Exam

Appearance/Behavior: apparent age, attitude and cooperativeness, eye

Speech: rate, rhythm, volume, tone, articulation

Mood: patient’s subjective emotional state—depressed, anxious, sad,

Affect: objective emotional expression—euthymic, dysphoric, euphoric,

Thought process: logical/linear, circumstantial, tangential, flight of

Thought content: suicidal/homicidal ideation, delusions, preoccupa-

Perceptual disturbances: hallucinations, illusions, derealization, deper-

Fund of knowledge: current events

Abstract thought: interpretation of proverbs, analogies

Insight: patient’s awareness of his/her illness and need for treatment

Judgment: patient’s ability to approach his/her problems in an appropri-

Characteristics: acute onset, waxing/waning sensorium (worse at night),

Etiology: drugs (narcotics, benzodiazepines, anticholinergics, TCAs, ste-

Management: identify/correct underlying cause, simplify Rx regi-

(hypnagogic hallucination) or upon awakening (hypnopompic hal