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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
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Notice
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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.
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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.
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Chapter IV.
The Crime at Heatherfield
“That's a fine old turkey-cock,” Dr. Ringwood commented, as he
and Sir Clinton groped their way down the drive towards the gate of
Ivy Lodge.
The Chief Constable smiled covertly at the aptness of the
description.
“He certainly did gobble a bit at the start,” he admitted. “But that
type generally stops gobbling if you treat it properly. I shouldn't care
to live with him long, though. A streak of the domestic tyrant in him
somewhere, I'm afraid.”
Dr. Ringwood laughed curtly.
“It must have been a pretty household,” he affirmed. “You didn't
get much valuable information out of him, in spite of all his self-
importance and fuss.”
“A character-sketch or two. Things like that are always useful
when one drops like a bolt from the blue into some little circle, as we
have to do in cases of this sort. I suppose it's the same in your own
line when you see a patient for the first time: he may be merely a
hypochondriac or he may be out of sorts. You've nothing to go on in
the way of past experience of him. We're in a worse state, if
anything, because you can't have a chat with a dead man and find
out what sort of person he was. It's simply a case of collecting other
people's impressions of him in a hurry and discarding about half that
you hear, on the ground of prejudice.”
“At least you'll get his own impressions this time, if it's true that he
kept a diary,” the doctor pointed out.
“It depends on the diary,” Sir Clinton amended. “But I confess to
some hopes.”
As they drew near the door of Heatherfield, Dr. Ringwood's
thoughts reverted to the state of things in the house. Glancing up at
the front, his eye was caught by a lighted window which had been
dark on his previous visit.
“That looks like a bedroom up there with the light on,” he pointed
out to his companion. “It wasn't lit up last time I was here. Perhaps
Silverdale or his wife has come home.”
A shapeless shadow swept momentarily across the curtains of
the lighted room as they watched.
“That's a relief to my mind,” the doctor confessed. “I didn't quite
like leaving that maid alone with my patient. One never can tell what
may happen in a fever case.”
As they were ascending the steps, a further thought struck him.
“Do you want to be advertised here—your name, I mean?”
“I think not, at present, so long as I can telephone without being
overheard.”
“Very well. I'll fix it,” Dr. Ringwood agreed, as he put his finger on
the bell-push.
Much to his surprise, his ring brought no one to the door.
“That woman must be deaf, surely,” he said, as he pressed the
button a second time. “She came quick enough the last time I was
here. I hope nothing's gone wrong.”
Sir Clinton waited until the prolonged peal of the bell ended when
the doctor took his finger away, then he bent down to the slit of the
letter-box and listened intently.
“I could swear I heard someone moving about, just then,” he said,
as he rose to his full height again. “There must be someone on the
premises to account for the shadow we saw at the window. This
looks a bit rum, doctor. Ring again, will you?”
Dr. Ringwood obeyed. They could hear the trilling of a heavy
gong somewhere in the back of the house.
“That ought to wake anyone up, surely,” he said with a nervous
tinge in his voice. “This is my second experience of the sort this
evening. I don't much care about it.”
They waited for a minute, but no one came to the door.
“It's not strictly legal,” Sir Clinton said at last, “but we've got to get
inside somehow. I think we'll make your patient an excuse, if the
worst comes to the worst. Just wait here a moment and I'll see what
can be done.”
He went down the steps and disappeared in the fog. Dr.
Ringwood waited for a minute or two, and then steps sounded in the
hall behind the door. Sir Clinton opened it and motioned him to come
in.
“The place seems to be empty,” he said hurriedly. “Stay here and
see that no one passes you. I want to go round the ground floor first
of all.”
He moved from door to door in the hall, switching on the lights
and swiftly inspecting each room as he came to it.
“Nothing here,” he reported, and then made his way into the
kitchen premises.
Dr. Ringwood heard his steps retreating; then, after a short
interval, there came the sound of a door closing and the shooting of
a bolt. It was not long before Sir Clinton reappeared.
“Somebody's been on the premises,” he said curtly. “That must
have been the sound I heard. The back door was open.”
Dr. Ringwood felt himself at a loss amid the complexities of his
adventures.
“I hope that confounded maid hasn't got the wind up and cleared
out,” he exclaimed, his responsibility for his patient coming foremost
in the confusion of the situation.
“No use thinking of chasing anyone through this fog,” Sir Clinton
confessed, betraying in his turn his own professional bias. “Whoever
it was has got clean away. Let's go upstairs and have a look round,
doctor.”
Leading the way, he snapped down the switch at the foot of the
stair-case; but to Dr. Ringwood's surprise, no light appeared above.
Sir Clinton pulled a flash-lamp from his pocket and hurried towards
the next flat; as he rounded the turn of the stair, he gave a muffled
exclamation. At the same moment, a high-pitched voice higher up in
the house broke into a torrent of aimless talk.
“That girl's a bit delirious,” Dr. Ringwood diagnosed, as he heard
the sound; and he quickened his ascent. But as he reached a little
landing and could see ahead of him, he was brought up sharply by
the sight which met his eyes. Sir Clinton was bending with his flash-
lamp over a huddled mass which lay on the floor at the head of the
flight, and a glance showed the doctor that it was the body of the
maid who had admitted him to the house on his earlier visit.
“Come here, doctor, and see if anything can be done for her,” Sir
Clinton's voice broke in on his surprise.
He leaped up the intervening steps and stooped in his turn over
the body, while Sir Clinton made way for him and kept the flash-lamp
playing on the face. Down the well of the stairs came the voice of the
delirious patient, sunk now to a querulous drone.
The briefest examination showed that the victim was beyond
help.
“We might try artificial respiration, but it would really be simply
time lost. She's been strangled pretty efficiently.”
Sir Clinton's face had grown dark as he bent over the body, but
his voice betrayed nothing of his feelings.
“Then you'd better go up and look after that girl upstairs, doctor.
She's evidently in a bad way. I'll attend to things here.”
Dr. Ringwood mechanically switched on the light of the next flight
in the stairs and then experienced a sort of subconscious surprise to
find it in action.
“I thought the fuse had gone,” he explained involuntarily, as he
hurried up the stairs.
Left to himself, Sir Clinton turned his flash-lamp upwards on to
the functionless electric light bracket above the landing and saw, as
he had expected, that the bulb had been removed from the socket. A
very short search revealed the lamp itself lying on the carpet. The
Chief Constable picked it up gingerly and examined it minutely with
his pocket-light; but his scrutiny merely proved that the glass was
unmarked by any recent finger-prints. He put it carefully aside,
entered the lighted bedroom, and secured a fresh bulb from one of
the lamp-sockets there.
With this he returned to the landing and glanced round in search
of something on which to stand, so that he could put the new bulb in
the empty socket. The only available piece of furniture was a small
table untidily covered with a cloth, which stood in one corner of the
landing. Sir Clinton stepped across to it and inspected it minutely.
“Somebody's been standing on that,” he noted. “But the traces
are just about nil. The cloth's thick enough to have saved the table-
top from any marks of his boot-nails.”
Leaving the table untouched, he re-entered the room he had
already visited and secured another small table, by means of which
he was able to climb up and fix the new bulb in the empty socket
over the landing. It refused to light, however, and he had to go to the
foot of the stairs and reverse the switch before the current came on.
Shutting off his flash-lamp, Sir Clinton returned to the landing and
bent once more over the body. The cause of death was perfectly
apparent: a cord with a rough wooden handle at each end had been
slipped round the woman's throat and had been used as a tourniquet
on her neck. The deep biting of the cord into the flesh indicated with
sufficient plainness the brutality of the killer. Sir Clinton did not
prolong his examination, and when he had finished, he drew out his
pocket-handkerchief and covered the distorted face of the body. As
he did so, Dr. Ringwood descended the stairs behind him.
“I'll need to telephone for the hospital van,” he said. “It's out of the
question to leave that girl here in the state she's in.”
Sir Clinton nodded his agreement. Then a thought seemed to
strike him.
“Quite off her rocker, I suppose?” he demanded. “Or did she
understand you when you spoke to her?”
“Delirious. She didn't even seem to recognise me,” Dr. Ringwood
explained shortly.
Then the reason for the Chief Constable's questions seemed to
occur to him.
“You mean she might be able to give evidence? It's out of the
question. She's got a very bad attack. She won't remember anything,
even if she's seen something or heard sounds. You'd get nothing out
of her.”
Sir Clinton showed no particular disappointment.
“I hardly expected much.”
Dr. Ringwood continued his way down stairs and made his way to
the telephone. When he had sent his message, he walked up again
to the first floor. A light was on in one of the rooms, and he pushed
open the door and entered, to find Sir Clinton kneeling on the floor in
front of an antique chest of drawers.
A glance round the room showed the doctor that it belonged to
Mrs. Silverdale. Through the half-open door of a wardrobe he caught
sight of some dresses; the dressing-table was littered with feminine
knick-knacks, among which was a powder-puff which the owner had
not replaced in its box; a dressing-jacket hung on a chair close to the
single bed. The whole room betrayed its constant use by some
woman who was prepared to spend time on her toilette.
“Found anything further?” Dr. Ringwood inquired as Sir Clinton
glanced up from his task.
“Nothing except this.”
The Chief Constable indicated the lowest drawer in front of him.
“Somebody's broken the lock and gone inside in a hurry. The
drawer's been shoved home anyhow and left projecting a bit. It
caught my eye when I came in.”
He pulled the drawer open as he spoke, and Dr. Ringwood
moved across and looked down into it over the Chief Constable's
shoulder. A number of jewel-boxes lay in one corner, and Sir Clinton
turned his attention to these in the first place. He opened them, one
after another, and found the contents of most of them in place. One
or two rings, and a couple of small articles seemed to be missing.
“Quite likely these are things she's wearing to-night,” he
explained, replacing the leather cases in the drawer as he spoke.
“We'll try again.”
The next thing which came to his hand was a packet of
photographs of various people. Among them was one of young
Hassendean, but it seemed to have no special value for Mrs.
Silverdale, since it had been carelessly thrust in among the rest of
the packet.
“Nothing particularly helpful there, it seems,” was Sir Clinton's
opinion.
He turned next to several old dance-programmes which had been
preserved with some care. Lifting them in turn and holding them so
that the doctor could see them, the Chief Constable glanced at the
scribbled names of the various partners.
“One gentleman seems to have been modest, anyhow,” he
pointed out. “No initials, even—just an asterisk on the line.”
He flipped the programmes over rapidly.
“Mr. Asterisk seems to be a favourite, doctor. He occurs pretty
often at each dance.”
“Her dancing-partner, probably,” Dr. Ringwood surmised. “Young
Hassendean, most likely, I should think.”
Sir Clinton put down the programmes and searched again in the
drawer. His hand fell on a battered notebook.
“Part of a diary she seems to have kept while she was in a
convent. . . . H'm! Just a school-girl's production,” he turned over a
few pages, reading as he went, “and not altogether a nice school-
girl,” he concluded, after he had paused at one entry. “There's
nothing to be got out of that just now. I suppose it may be useful later
on, in certain circumstances.”
He laid the little book down again and turned once more to the
drawer.
“That seems to be the lot. One thing's pretty clear. The person
who broke that lock wasn't a common burglar, for he'd have pouched
the trinkets. The bother is that we ought to find out what this search
was for; and since the thing has probably been removed, it leaves
one with a fairly wide field for guessing. Let's have another look
round.”
Suddenly he bent forward and picked up a tiny object from the
bottom of the drawer. As he lifted it, Dr. Ringwood could see that it
was a scrap of paper; and when it was turned over he recognised it
as a fragment torn from the corner of an envelope with part of the
stamp still adhering to it.
“H'm! Suggestive rather than conclusive,” was Sir Clinton's
verdict. “My first guess would be that this has been torn off a
roughly-opened letter. So there must have been letters in this drawer
at one time or another. But whether our murderous friend was after a
packet of letters or not, one can't say definitely.”
He stood up and moved under the electric light in order to
examine the fragment closely.
“It's got the local post-mark on it. I can see the VEN. The date's
1925, but the month part has been torn.”
He showed the scrap to Dr. Ringwood and then placed it carefully
in his note-case.
“I hate jumping to conclusions, doctor; but it certainly does look
as if someone had broken in here to get hold of letters. And they
must have been pretty important letters if it was worth while to go the
length of casual murder to secure them.”
Dr. Ringwood nodded.
“He must have been a pretty hard case to murder a defenceless
woman.”
Sir Clinton's face showed a faint trace of a smile.
“There are two sexes, doctor.”
“What do you mean? . . . Oh, of course. I said ‘he must,’ and you
think it might have been a woman?”
“I don't think so; but I hate to prejudge the case, you know. All
that one can really say is that someone came here and killed that
unfortunate woman. The rest's simply conjecture and may be right or
wrong. It's easy enough to make up a story to fit the facts.”
Dr. Ringwood walked across to the nearest chair and sat down.
“My brain's too fagged to produce anything of the sort, I'm afraid,”
he admitted, “but I'd like to hear anything that would explain the
damned business.”
Sir Clinton closed the drawer gently and turned round to face the
doctor.
“Oh, it's easy enough,” he said, “whether it's the true solution or
not's quite another question. You came here about twenty past ten,
were let in by the maid, saw your patient, listened to what the maid
had to tell you—lucky for us you took that precaution or we'd have
missed all that evidence, since she can't tell us now—and left this
house at twenty-five to eleven. We came back again, just an hour
later. The business was done in between those times, obviously.”
“Not much theory there,” the doctor pointed out.
“I'm simply trying it over in my mind,” Sir Clinton explained, “and
it's just as well to have the time-limits clear to start with. Now we go
on. Some time after you had got clear away from here, the murderer
comes along. Let's call that person X, just to avoid all prejudice
about age or sex. Now X has thought out this murder beforehand,
but not very long beforehand.”
“How do you make that out?” Dr. Ringwood demanded.
“Because the two bits of wood which form the handles of the
tourniquet are simply pieces cut off a tree, and freshly cut, by the
look of the ends. X must have had possession of these before
coming into the house—hence premeditation. But if it had been a
case of long premeditation, X would have had something better in
the way of handles. I certainly wouldn't have risked landing on a
convenient branch at the last moment if I'd been doing the job
myself; and X, I may say, strikes me as a remarkably cool,
competent person, as you'll see.”
“Go on,” the doctor said, making no attempt to conceal his
interest.
“Our friend X probably had the cord in his or her pocket and had
constructed the rough tourniquet while coming along the road. Our
friend X was wearing gloves, I may say.”
“How do you know that?” Ringwood asked.
“You'll see later. Now X went up to the front door and rang the
bell. The maid came along, recognised X. . . .”
“How do you know that?” Ringwood repeated.
“I don't know it. I’m just giving you the hypothesis you asked for. I
don't say it's correct. To continue: this person X inquired if Silverdale
(or Mrs. Silverdale, perhaps) was at home. Naturally the maid said
no. Most likely she told X that her companion had scarlatina. Then X
decided to leave a note, and was invited into the house to write it. It
was a long note, apparently; and the maid was told to go to the
kitchen and wait till X had finished. So off she went.”
“Well?”
“X had no intention of putting pen to paper, of course. As soon as
the maid was out of the way, X slipped upstairs and switched on the
light in this room.”
“I'd forgotten it was the light in this window that we saw from the
outside,” Dr. Ringwood interrupted. “Go on.”
“Then, very quietly, by shifting the table on the landing under the
electric light, X removed the bulb that lighted the stair. One can
reach it by standing on that table. Then X shifted the table back to its
place. There were no finger-prints on the bulb—ergo, X must have
been wearing gloves, as I told you.”
“You seem to have got a lot of details,” the doctor admitted. “But
why all this manœuvring?”
“You'll see immediately. I think I said already that whoever did the
business was a very cool and competent person. When all was
ready, X attracted the maid's attention in some way. She came to the
foot of the stairs, suspecting nothing, but probably wondering what X
was doing, wandering about the house. It's quite likely that X made
the sick girl upstairs the pretext for calling and wandering out of
bounds. Anyhow, the maid came to the foot of the stairs and moved
the switch of the landing light. Nothing happened, of course, since
the bulb had been removed. She tried the switch backwards and
forwards once or twice most likely, and then she would conclude that
the lamp was broken or the fuse gone. Probably she saw the
reflection of the light from the room-door. In any case, she came
quite unsuspiciously up the stair.”
Sir Clinton paused, as though to allow the doctor to raise
objections; but none came, so he continued:
“Meanwhile X had taken up a position opposite the door of the
room, at the foot of the second flight of stairs. If you remember, a
person crouching there in semi-darkness would be concealed from
anyone mounting the first flight. The tourniquet was ready, of
course.”
Dr. Ringwood shuddered slightly. Apparently he found Sir
Clinton's picture a vivid one, in spite of the casual tone in which it
had been drawn.
“The girl came up, quite unsuspicious,” Sir Clinton continued.
“She knew X; it wasn't a question of a street-loafer or anything of
that sort. An attack would be the last thing to cross her mind. And
then, in an instant, the attack fell. Probably she turned to go into the
lighted room, thinking that X was there; and then the noose would be
round her neck, a knee would be in her back and . . .”
With a grim movement, Sir Clinton completed his narrative of the
murder more effectively than words could have done.
“That left X a clear field. The girl upstairs was light-headed and
couldn't serve as a witness. X daren't go near her for fear of catching
scarlatina—and that would have been a fatal business, for naturally
we shall keep our eye on all fresh scarlet cases for the next week or
so. It's on the cards that her scarlatina has saved her life.”
Dr. Ringwood's face showed his appreciation of this point.
“And then?” he pressed Sir Clinton.
“The rest's obvious. X came in here, hunting for something which
we haven't identified. Whatever it was, it was in this drawer and X
knew where it was. Nothing else has been disturbed except slightly
—possibly in a hunt for the key of the drawer in case it had been left
lying around loose. Not finding the key, X broke open the drawer and
then we evidently arrived. That must have been a nasty moment up
here. I don't envy friend X's sensations when we rang the front door
bell. But a cool head pulls one through difficulties of that sort. While
we were standing unsuspiciously on the front door steps, X slipped
down stairs, out of the back door, and into the safety of the fog-
screen.”
The Chief Constable rose to his feet as he concluded.
“Then that's what happened, you think?” Doctor Ringwood asked.
“That's what may have happened,” Sir Clinton replied cautiously.
“Some parts of it certainly are correct, since there's sound evidence
to support them. The rest's no more than guess-work. Now I must go
to the 'phone.”
As the Chief Constable left the room, the sick girl upstairs
whimpered faintly, and Dr. Ringwood got out of his chair with a yawn
which he could not suppress. He paused on the threshold and
looked out across the body to the spot at the turn of the stair. Sir
Clinton's word-picture of the murderer crouching there in ambush
with his tourniquet had been a little too vivid for the doctor's
imagination.
Chapter V.
The Bungalow Tragedy
In the course of his career, Sir Clinton Driffield had found it
important to devote some attention to his outward appearance; but
his object in doing so had been different from that of most men, for
he aimed at making himself as inconspicuous as possible. To look
well-dressed, but not too smart; to seem intelligent without betraying
his special acuteness; to be able to meet people without arousing
any speculations about himself in their minds; above all, to eliminate
the slightest suggestion of officialism from his manner: these had
been the objects of no little study on his part. In the days when he
had held junior posts, this protective mimicry of the average man had
served his purposes excellently, and he still cultivated it even though
its main purpose had gone.
Seated at his office desk, with its wire baskets holding packets of
neatly-docketed papers, he would have passed as a junior director in
some big business firm. Only a certain tiredness about his eyes
hinted at the sleepless night he had spent at Heatherfield and Ivy
Lodge, and when he began to open his letters, even this symptom
seemed to fade out.
As he picked up the envelopes before him, his eye was caught by
the brown cover of a telegram, and he opened it first. He glanced
over the wording and his eyebrows lifted slightly. Then, putting down
the document, he picked up his desk-telephone and spoke to one of
his subordinates.
“Has Inspector Flamborough come in?”
“Yes, sir. He's here just now.”
“Send him along to me, please.”
Replacing the telephone on its bracket, Sir Clinton picked up the
telegram once more and seemed to reconsider its wording. He
looked up as someone knocked on the door and entered the room.
“Morning, Inspector. You're looking a bit tired. I suppose you've
fixed up all last night's business?”
“Yes, sir. Both bodies are in the mortuary; the doctor's been
warned about the P.M.’s; the coroner's been informed about the
inquests. And I've got young Hassendean's papers all collected. I
haven't had time to do more than glance through them yet, sir.”
Sir Clinton gave a nod of approval and flipped the telegram
across his desk.
“Sit down and have a look at that, Inspector. You can add it to
your collection.”
Flamborough secured the slip of paper and glanced over it as he
pulled a chair towards the desk.
“ ‘Chief Constable, Westerhaven. Try hassendean bungalow
lizardbridge road justice.’ H'm! Handed in at the G.P.O. at 8.5 a.m.
this morning. Seems to err a bit on the side of conciseness. He could
have had three more words for his bob, and they wouldn't have
come amiss. Who sent it, sir?”
“A member of the Order of the Helpful Hand, perhaps. I found it
on my desk when I came in a few minutes ago. Now you know as
much about it as I do, Inspector.”
“One of these amateur sleuths, you think, sir?” asked the
Inspector, and the sub-acid tinge in his tone betrayed his opinion of
uninvited assistants. “I had about my fill of that lot when we were
handling that Laxfield affair last year.”
He paused for a moment, and then continued:
“He's been pretty sharp with his help. It's handed in at 8.5 a.m.
and the only thing published about the affair is a stop-press note
shoved into the Herald. I bought a copy as I came along the road.
Candidly, sir, it looks to me like a leg-pull.”
He glanced over the telegram disparagingly.
“What does he mean by ‘Lizardbridge road justice’? There's no
J.P. living on the Lizardbridge Road; and even if there were, the thing
doesn't make sense to me.”
“I think ‘justice’ is the signature, Inspector—what one might term
his nom-de-kid, if one leaned towards slang, which of course you
never do.”
The Inspector grinned. His unofficial language differed
considerably from his official vocabulary, and Sir Clinton knew it.
“Justice? I like that!” Flamborough ejaculated contemptuously, as
he put the telegram down on the desk.
“It looks rather as though he wanted somebody's blood,” Sir
Clinton answered carelessly. “But all the same, Inspector, we can't
afford to put it into the waste-paper basket. We're very short of
anything you could call a real clue in both these cases last night,
remember. It won't do to neglect this, even if it does turn out to be a
mare's nest.”
Inspector Flamborough shrugged his shoulders almost
imperceptibly, as though to indicate that the decision was none of
his.
“I'll send a man down to the G.P.O. to make inquiries at once, sir,
if you think it necessary. At that time in the morning there can't have
been many wires handed in and we ought to be able to get some
description of the sender.”
“Possibly,” was as far as Sir Clinton seemed inclined to go. “Send
off your man, Inspector. And while he's away, please find out
something about this Hassendean Bungalow, as our friend calls it.
It's bound to be known to the Post Office people, and you'd better
get on the local P.O. which sends out letters to it. The man who
delivers the post there will be able to tell you something about it. Get
the 'phone to work at once. If it's a hoax, we may as well know that
at the earliest moment.”
“Very well, sir,” said the Inspector, recognising that it was useless
to convert Sir Clinton to his own view.
He picked up the telegram, put it in his pocket, and left the room.
When the Inspector had gone, Sir Clinton ran rapidly through his
letters, and then turned to the documents in the wire baskets. He
had the knack of working his mind by compartments when he chose,
and it was not until Flamborough returned with his report that the
Chief Constable gave any further thought to the Hassendean case.
He knew that the Inspector could be trusted to get the last tittle of
useful information when he had been ordered to do so.
“The Hassendeans have a bungalow on the Lizardbridge Road,
sir,” Flamborough confessed when he came back once more. “I got
the local postman to the 'phone and he gave me as much as one
could expect. Old Hassendean built the thing as a spec., hoping to
get a good price for it. Ran it up just after the war. But it cost too
much, and he's been left with it on his hands. It's just off the road, on
the hill about half-way between here and the new place they've been
building lately, that farm affair.”
“Oh, there?” Sir Clinton answered. “I think I know the place. I've
driven past it often: a brown-tiled roof and a lot of wood on the front
of the house.”
“That's it, sir. The postman described it to me.”
“Anything more about it?”
“It's empty most of the year, sir. The Hassendeans use it as a
kind of summer place—shift up there in the late spring, usually, the
postman said. It overlooks the sea and stands high, you remember.
Plenty of fresh air. But it's shut up just now, sir. They came back to
town over two months ago—middle of September or thereabouts.”
Sir Clinton seemed to wake up suddenly.
“That fails to stir you, Inspector? Strange! Now it interests me
devilishly, I can assure you. We'll run up there now in my car.”
The Inspector was obviously disconcerted by this sudden desire
for travel.
“It's hardly worth your while to go all that way, sir,” he protested. “I
can easily go out myself if you think it necessary.”
Sir Clinton signed a couple of documents before replying. Then
he rose from his chair.
“I don't mind saying, Inspector, that two murders within three
hours is too high an average for my taste when they happen in my
district. It's a case of all hands to the pumps, now, until we manage
to get on the track. I'm not taking the thing out of your hands. It's
simply going on the basis that two heads are better than one. We've
got to get to the bottom of the business as quick as we can.”
“I quite understand, sir,” Flamborough acknowledged without
pique. “There's no grudge in the matter. I'm only afraid that this
business is a practical joke and you'll be wasting your time.”
Sir Clinton dissented from the last statement with a movement of
his hand.
“By the way,” he added, “we ought to take a doctor with us. If
there's anything in the thing at all, I've a feeling that Mr. Justice
hasn't disturbed us for a trifle. Let's see. Dr. Steel will have his hands
full with things just now; we'll need to get someone else. That
Ringwood man has his wits about him, from what I saw of him. Ring
him up, Inspector, and ask him if he can spare the time. Tell him
what it's about, and if he's the sportsman I take him for, he'll come if
he can manage it. Tell him we'll call for him in ten minutes and bring
him home again as quick as we can. And get them to bring my car
round now.”
Twenty minutes later, as they passed up an avenue, Sir Clinton
turned to Dr. Ringwood:
“Recognise it, doctor?”
Dr. Ringwood shook his head.
“Never seen it before to my knowledge.”
“You were here last night, though. Look, there's Ivy Lodge.”
“So I see by the name on the gate-post. But remember it's the
first time I've seen the house itself. The fog hid everything last night.”
Sir Clinton swung the car to the left at the end of the avenue.
“We shan't be long now. It's a straight road out from here to the
place we're bound for.”
As they reached the outskirts of Westerhaven, Sir Clinton
increased his speed, and in a very short time Dr. Ringwood found
himself approaching a long low bungalow which faced the sea-view
at a little distance from the road. It had been built in the shelter of a
plantation, the trees of which dominated it on one side; and the
garden was dotted with clumps of quick-growing shrubs which
helped to give it the appearance of maturity.
Inspector Flamborough stepped down from the back seat of the
car as Sir Clinton drew up.
“The gate's not locked,” he reported, as he went up to it. “Just
wait a moment, sir, while I have a look at the surface of the drive.”
He walked a short distance towards the house, with his eyes on
the ground; then he returned and swung the leaves of the gate open
for the car to pass.
“You can drive in, sir,” he reported. “The ground was hard last
night, you remember; and there isn't a sign of anything in the way of
footmarks or wheel-prints to be seen there.”
As the car passed him, he swung himself aboard again; and Sir
Clinton drove up to near the house.
“We'll get down here, I think, and walk the rest,” he proposed,
switching off his engine. “Let's see. Curtains all drawn. . . . Hullo!
One of the small panes of glass on that front window has been
smashed, just at the lever catch. You owe an apology to Mr. Justice,
Inspector, I think. He's not brought us here to an absolute mare's
nest, at any rate. There's been housebreaking going on.”
Followed by the others, he walked over to the damaged window
and examined it carefully.
“No foot-prints or anything of that sort to be seen,” he pointed out,
glancing at the window-sill. “The window's been shut, apparently,
after the housebreaker got in—if he did get in at all. That would be
an obvious precaution, in case the open window caught someone's
eye.”
He transferred his attention to the casement itself. It was a steel-
framed one, some four feet high by twenty inches wide, which
formed part of a set of three which together made up the complete
window. Steel bars divided it into eight small panes.
“The Burglar's Delight!” Sir Clinton described it scornfully. “You
knock in one pane, just like this; then you put your hand through;
turn the lever-fastener; swing the casement back on its hinges—and
walk inside. There isn't even the trouble of hoisting a sash as you
have to do with the old-fashioned window. Two seconds would see
you inside the house, with only this affair to tackle.”
He glanced doubtfully at the lever handle behind the broken
glass.
“There might be finger-prints on that,” he said. “I don't want to
touch it. Just go round to the front door, Inspector, and see if it's
open by any chance. If not, we'll smash the glass at the other end of
this window and use the second casement to get in by, so as not to
confuse things.”
When the Inspector had reported the front door locked, the Chief
Constable carried out his proposal; the untouched casement swung
open, and they prepared to enter the room, which hitherto had been
concealed from them by the drawn curtains. Sir Clinton led the way,
and as he pushed the curtain out of his road, his companions heard
a bitten-off exclamation.
“Not much of a mare's nest, Inspector,” he continued in a cooler
tone. “Get inside.”
The Inspector, followed by Dr. Ringwood, climbed through the
open casement and stared in astonishment at the sight before them.
The place they had entered was evidently one of the sitting-rooms of
the bungalow, and the dust-sheets which covered the furniture
indicated that the building had been shut up for the winter. In a big
arm-chair, facing them as they entered, sat the body of a girl in
evening dress with a cloak around her shoulders. A slight trail of
blood had oozed from a wound in her head and marked her shoulder
on the right side. On the floor at her feet lay an automatic pistol. One
or two small chairs seemed to have been displaced roughly in the
room, as though some struggle had taken place; but the attitude of
the girl in the chair was perfectly natural. It seemed as though she
had sat down merely to rest and death had come upon her without
any warning, for her face had no tinge of fear in its expression.
“I wasn't far out in putting my money on Mr. Justice, Inspector,”
Sir Clinton said thoughtfully, as he gazed at the dead girl. “It might
have been days before we came across this affair without his help.”
He glanced round the room for a moment, biting his lip as though
perplexed by some problem.
“We'd better have a general look round before touching the
details,” he suggested, at last; and he led the way out of the room
into the hall of the bungalow. “We'll try the rooms as we come to
them.”
Suiting the action to the word, he opened the first door that came
to hand. It proved to be that of a dismantled bedroom. The dressing-
table was bare and everything had been removed from the bed
expect a wire mattress. The second door led into what was obviously
the dining-room of the bungalow; and here again the appearance of
the room showed that the house had been shut up for the season. A
third trial revealed a lavatory.
“H'm! Clean towels hanging on the rail?” Sir Clinton pointed out.
“That's unusual in an empty house, isn't it?”
Without waiting for a minuter examination, he turned to the next
door.
“Some sort of store-room, apparently. These mattresses belong
to the beds, obviously.”
Along one side of the little room were curtained shelves. Sir
Clinton slid back the curtains and revealed the stacked house-
napery, towels, and sheets.
“Somebody seems to have been helping themselves here,” he
indicated, drawing his companions’ attention to one or two places
where the orderly piling of the materials had been disturbed by
careless withdrawals. “We'll try again.”
The next room provided a complete contrast to the rest of the
house. It was a bedroom with all its fittings in place. The bed, fully
made up, had obviously not been slept in. The dressing-table was
covered with the usual trifles which a girl uses in her toilette. Vases,
which obviously did not belong to the normal equipment of the room,
had been collected here and filled with a profusion of expensive
flowers. Most surprising of all, an electric stove, turned on at half
power, kept the room warm.
“She's been living here!” the Inspector exclaimed in a tone which
revealed his astonishment.
Sir Clinton made a gesture of dissent. He crossed the room, and
threw open the door of a cupboard wardrobe, revealing empty hooks
and shelves.
“She'd hardly be living here with nothing but an evening frock in
the way of clothes, would she?” he asked. “You can look round if you
like, Inspector; but I'm prepared to bet that she never set foot in this
room. You won't find much.”
He stepped over to the dressing-table and examined one by one
the knick-knacks placed upon it.
“These things are all split-new, Inspector. Look at this face-
powder box—not been opened, the band's still intact on it. And the
lip-stick's unused. You can see that at a glance.”
Flamborough had to admit the truth of his superior's statements.
“H'm!” he reflected. “Of course it's Mrs. Silverdale, I suppose,
sir?”
“I should think so, but we can make sure about it very soon. In
the meantime, let's finish going round the premises.”
The rest of the survey revealed very little. The remainder of the
house was obviously dismantled for the winter. Only once did Sir
Clinton halt for any time, and that was in the pantry. Here he
examined the cups suspended from hooks on the wall and pointed
out to Flamborough the faint film of accumulated dust on each of
them.
“None of that crockery has been used for weeks, Inspector. One
can't live in a house without eating and drinking, you know.”
“A port of call, then?” the Inspector persisted. “She and young
Hassendean could drop in here without rousing any suspicion.”
“Perhaps,” Sir Clinton conceded abstractedly. “Now we'll get Dr.
Ringwood to give his assistance.”
He led the way back to the room through which they had entered
the house.
“She was dead before that shot was fired, of course,” he said as
they crossed the threshold. “But beyond that there ought to be
something to be seen.”
“What makes you so sure that the shot didn't kill her, sir?” the
Inspector demanded.
“Because there wasn't half enough blood scattered about the
place. She was dead when the shot was fired—must have been
dead for some minutes, I suspect. There was no heart-action to lift
the blood in her body, so consequently it sank under gravity and left
her skull nearly empty of it. Then when the shot was fired, only the
merest trickle came from the wound. I think that's right, isn't it,
doctor?”
“It's quite on the cards,” Dr. Ringwood agreed. “Certainly there
wasn't the normal amount of bleeding that one might have
expected.”
“Then the really important point is: how did she come to die. This
is where we rely on you, doctor. Go ahead, please, and see what
you make of it.”
Dr. Ringwood went over to the arm-chair and began his
examination of the dead girl. His glance travelled first to the open

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First Aid for the Psychiatry Clerkship,

Fourth Edition Latha Ganti

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First Aid for the USMLE Step 1 2020, Thirtieth edition

Tips on what to know to IMPRESS

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

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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-

(hypnagogic hallucination) or upon awakening (hypnopompic hal