(BQ) Part 2 book “Pocket handbook of clinical psychiatry” has contents: Sexual dysfunction and gender dysphoria, feeding and eating disorders, obesity and metabolic syndrome, child psychiatry, psychosomatic medicine, geriatric psychiatry, psychopharmacological treatment and nutritional supplements, brain stimulation therapies,… and other contents.
18 Sexual Dysfunction and Gender Dysphoria Sexual dysfunctions are an inability to respond to sexual stimulation, or the experience of pain during the sexual act It is defined by disturbance in the subjective sense of pleasure or desire associated with sex, or by the objective performance In the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), the sexual dysfunctions include male hypoactive sexual desire disorder, female sexual interest/arousal disorder, erectile disorder, female orgasmic disorder, delayed ejaculation, premature (early) ejaculation, genitopelvic pain/penetration disorder, substance/medication-induced sexual dysfunction, other specified sexual dysfunction, and unspecified sexual dysfunction If more than one dysfunction exists, they should all be diagnosed Sexual dysfunctions can be lifelong or acquired, generalized or situational, and result from psychological factors, physiologic factors, or combined factors As per DSM-5 dysfunction due to a general medical condition, substance use, or adverse effects of medication should be noted Sexual dysfunction may be diagnosed in conjunction with another psychiatric disorder (depressive disorders, anxiety disorders, personality disorders, and schizophrenia) I Desire, Interest, and Arousal Disorders A Male hypoactive sexual desire disorder Characterized by a lack or absence of sexual fantasies and desire for minimum duration of months Men may have never experienced erotic/sexual thoughts and the dysfunction can be lifelong The prevalence is greatest in the younger (6% of men ages 18 to 24) and older (40% of men ages 66 to 74) with only 2% aged 16 to 44 affected by this disorder Patients with desire problems often use inhibition of desire defensively, to protect against unconscious fears about sex Lack of desire can also result from chronic stress, anxiety, or depression or the use of various psychotropic drugs and other drugs that depress the central nervous system (CNS) In sex therapy clinic populations, lack of desire is one of the most common complaints among married couples, with women more affected than men The diagnosis should not be made unless the lack of desire is a source of distress to a patient See Table 18-1 B Female sexual interest/arousal disorder The combination of interest (or desire) and arousal reflects that women not necessarily move stepwise from desire to arousal, but experience desire synchronously with, or even following feelings of arousal Consequently, women may experience either/or both inability to feel interest or arousal, difficulty achieving orgasm or experience pain Usual complaints include decrease or paucity of erotic feelings, thoughts and fantasies; a decreased impulse to initiate sex; a decreased or absent receptivity to partner overtures and an inability to respond to partner stimulation Table 18-1 Male Hypoactive Sexual Desire Disorder Reduced or no sexual appetite or libido for ≥6 months Many factors such as age and culture should inform whether the patient fits within the bounds for normal sexual desire Subjective sense of arousal is poorly correlated with genital lubrication in both normal and dysfunctional women A woman complaining of lack of arousal may lubricate vaginally, but may not experience a subjective sense of excitement The prevalence is generally underestimated In one study of subjectively happily married couples, 33% of women described arousal problems Difficulty in maintaining excitement can reflect psychological conflicts (e.g., anxiety, guilt, and fear) or physiologic changes Alterations in testosterone, estrogen, prolactin, and thyroxin levels have been implicated in female sexual arousal disorder In addition, medications with antihistaminic or anticholinergic properties cause a decrease in vaginal lubrication Relationship problems are particularly relevant to acquired interest/arousal disorder In one study of couples with markedly decreased sexual interaction, the most prevalent etiology was marital discord See Table 18-2 C Male erectile disorder In lifelong male erectile disorder one has never been able to obtain an erection while in acquired type one has successfully achieved penetration at some time in his sexual life Erectile disorder is reported in 10% to 20% of all men and is the chief complaint of more than 50% of all men treated for sexual disorders Lifelong male erectile disorder is rare; it occurs in about 1% of men younger than age 35 The incidence increases with age and has been reported around 2% to 8% of the young adult population The rate increases to 40% to 50% in men between ages of 60 and 70 Male erectile disorder can be organic or psychological, or a combination but in young and middle-aged men the cause is usually psychological A history of spontaneous erections, morning erections, or good erections with masturbation or with partners other than the usual one indicates functional impotence Psychological causes of erectile dysfunction include a punitive conscience or superego, an inability to trust, or feelings of inadequacy Erectile dysfunction also may reflect relationship difficulties between partners See Table 18-3 Table 18-2 Female Sexual Interest/Arousal Disorder Reduced or no sexual appetite or libido for ≥6 months ≥3 of: Decreased interest in sex Decrease in thoughts about sex or imaginative scenarios Decreased receptivity to and engagement in sex Decreased enjoyment of sexual situations Decreased responsiveness to sexual cues Decrease in genital and nongenital reactions to sex Cannot be a sequela of severe relationship distress or significant stressors Table 18-3 Erectile Disorder Difficulty achieving or maintaining an erection, or in attaining erectile stiffness throughout almost all sexual efforts for ≥6 months Cannot be a sequela of severe relationship distress or significant stressors II Orgasm Disorders A Female orgasmic disorder Female orgasmic disorder (anorgasmia or inhibited female orgasm) is a recurrent or persistent delay in or absence of orgasm following a normal sexual excitement phase In lifelong female orgasmic disorder, one has never experienced an orgasm by any kind of stimulation while in acquired orgasmic disorder one has previously experienced at least one orgasm The disorder is more common among unmarried women The estimated proportion of married women over age 35 who never have achieved orgasm is 5% The proportion is higher in unmarried women and younger women The overall prevalence of inhibited female orgasm is 30% Psychological factors associated with inhibited orgasm include fears of impregnation or rejection by the sex partner, hostility toward men, feelings of guilt about sexual impulses, or marital conflicts See Table 18-4 B Delayed ejaculation In male delayed ejaculation (retarded ejaculation), a man achieves ejaculation during coitus with great difficulty, if at all The problem occurs mostly during coital activity Lifelong inhibited male orgasm usually indicates more severe psychopathology Acquired ejaculatory inhibition frequently reflects interpersonal difficulties The incidence is low compared to premature ejaculation and in one group of men was only 3.8% A general prevalence of 5% has been reported but more recently increased rates have been seen This has been attributed to the increasing use of antidepressants like selective serotonin reuptake inhibitors (SSRIs), which cause delayed orgasm See Table 18-5 C Premature (early) ejaculation In premature ejaculation, men persistently or recurrently achieve orgasm and ejaculation before they wish to The diagnosis is made when a man regularly ejaculates before or within approximately 1 minute after penetration It is more prevalent among young men, men with a new partner, and college-educated men than among men with less education; the problem with the latter group is thought to be related to concern for partner satisfaction Premature ejaculation is the chief complaint of 35% to 40% of men treated for sexual disorders Table 18-4 Female Orgasmic Disorder Reduction in frequency, immediacy, or intensity of orgasm Cannot be a sequela of severe relationship distress or significant stressors Table 18-5 Delayed Ejaculation Increase in latency or decrease in regularity of ejaculation during almost all sexual efforts for ≥6 months Cannot be a sequela of severe relationship distress or significant stressors Difficulty in ejaculatory control may be associated with anxiety regarding the sex act and with unconscious fears about the vagina It may also be the result of conditioning if the man’s early sexual experiences occurred in situations in which discovery would have been embarrassing A stressful marriage exacerbates the disorder Behavioral techniques are used in treatment However, a subgroup of premature ejaculators may be biologically predisposed; they are more vulnerable to sympathetic stimulation or they have a shorter bulbocavernosus reflex nerve latency time, and they should be treated pharmacologically with SSRIs or other antidepressants A side effect of these drugs is the inhibition of ejaculation The developmental background and the psychodynamics found in premature ejaculation and in erectile disorder are similar See Table 186 III Sexual Pain Disorders A Genito-pelvic pain/penetration disorder In DSM-5, this disorder refers to one or more of the following complaints, of which any two or more may occur together: difficulty having intercourse; genito-pelvic pain; fear of pain or penetration; and tension of the pelvic floor muscles Previously, these were diagnosed as dyspareunia or vaginismus and could coexist and lead to fear of pain with sex These diagnoses are categorized into one diagnostic category but for the purposes of clinical discussion the distinct categories of dyspareunia and vaginismus remain clinically useful See Table 18-7 Dyspareunia Dyspareunia is recurrent or persistent genital pain occurring before, during, or after intercourse Dyspareunia is related to vaginismus and repeated episodes of vaginismus can lead to dyspareunia DSM-5 cites that 15% of women in North America report recurrent pain during intercourse Table 18-6 Premature (Early) Ejaculation Undesired ejaculation during the first minute after (vaginal) penetration Ejaculation occurs prematurely during almost all sexual encounters (Duration criteria do not exist for other penetration sites.) Table 18-7 Genito-Pelvic Pain/Penetration Disorder Problems with at least one of: Vaginal penetration Extreme pelvic/vaginal pain during penetration attempts Anxiety about such pain Pelvic muscle clenching during penetration Though GPP should cause distress, it cannot be a sequela of severe relationship distress or significant stressors Chronic pelvic pain is a common complaint in women with a history of rape or childhood sexual abuse Painful coitus can result from tension and anxiety and makes intercourse unpleasant or unbearable Dyspareunia is uncommon in men and is usually associated with a medical condition (e.g., Peyronie’s disease) Dyspareunia may present as any of the four complaints listed under genito-pelvic pain/penetration disorder and should be diagnosed as genito-pelvic pain/penetration disorder Vaginismus Defined as a constriction of the outer third of the vagina due to involuntary pelvic floor muscle tightening or spasm, vaginismus interferes with penile insertion and intercourse Vaginismus may be complete, that is no penetration of the vagina is possible In a less severe form, pain makes penetration difficult, but not impossible It mostly afflicts highly educated women and of high socioeconomic groups A sexual trauma, such as rape, or unpleasant first coital experience may cause vaginismus A strict religious upbringing in which sex is associated with sin is frequent in these patients IV Sexual Dysfunction Due to a General Medical Condition A Male erectile disorder due to a general medical condition Statistics indicate that 20% to 50% of men with erectile disorder have an organic basis for the disorder A physiologic etiology is likely in men older than 50 and the most likely cause in men older than age 60 The organic causes of male erectile disorder are listed in Table 18-8 Following procedures may help differentiate organically caused erectile disorder from functional erectile disorder Monitoring nocturnal penile tumescence (erections during rapid eye movement sleep) Monitoring tumescence with a strain gauge Measuring blood pressure in the penis with a penile plethysmograph Other diagnostic include glucose tolerance tests, plasma hormone assays, liver and thyroid function tests, prolactin and follicle-stimulating hormone (FHS) determinations, and cystometric examinations Table 18-8 Diseases and Other Medical Conditions Implicated in Male Erectile Disorder Infectious and parasitic diseases Elephantiasis Mumps Cardiovascular diseasea Atherosclerotic disease Aortic aneurysm Leriche’s syndrome Cardiac failure Renal and urologic disorders Peyronie’s disease Chronic renal failure Hydrocele and varicocele Hepatic disorders Cirrhosis (usually associated with alcohol dependence) Pulmonary disorders Respiratory failure Genetics Klinefelter’s syndrome Congenital penile vascular and structural abnormalities Nutritional disorders Malnutrition Vitamin deficiencies Obesity Endocrine disordersa Diabetes mellitus Acromegaly Addison’s disease Chromophobe adenoma Adrenal neoplasia Myxedema Hyperthyroidism Neurologic disorders Multiple sclerosis Transverse myelitis Parkinson’s disease Temporal lobe epilepsy Traumatic and neoplastic spinal cord diseasesa Central nervous system tumor Amyotrophic lateral sclerosis Peripheral neuropathy General paresis Tabes dorsalis Pharmacologic factors Alcohol and other dependence-inducing substances (heroin, methadone, morphine, cocaine, amphetamines, and barbiturates) Prescribed drugs (psychotropic drugs, antihypertensive drugs, estrogens, and antiandrogens) Poisoning Lead (plumbism) Herbicides Surgical proceduresa Perineal prostatectomy Abdominal-perineal colon resection Sympathectomy (frequently interferes with ejaculation) Aortoiliac surgery Radical cystectomy Retroperitoneal lymphadenectomy Miscellaneous Radiation therapy Pelvic fracture Any severe systemic disease or debilitating condition aIn the United States an estimated 2 million men are impotent because they have diabetes mellitus; an additional 300,000 are impotent because of other endocrine diseases; 1.5 million are impotent as a result of vascular disease; 180,000 because of multiple sclerosis; 400,000 because of traumas and fractures leading to pelvic fractures or spinal cord injuries; and another 650,000 are impotent as a result of radical surgery, including prostatectomies, colostomies, and cystectomies B Dyspareunia due to a general medical condition An estimated 30% of all surgical procedures on the female genital area result in temporary dyspareunia In addition, 30% to 40% of women with the complaint who are seen in sex therapy clinics have pelvic pathology Organic abnormalities leading to dyspareunia and vaginismus include irritated or infected hymenal remnants, episiotomy scars, Bartholin’s gland infection, various forms of vaginitis and cervicitis, endometriosis, and adenomyosis Postcoital pain has been reported by women with myomata, endometriosis, and adenomyosis, and is attributed to the uterine contractions during orgasm Postmenopausal women may have dyspareunia resulting from thinning of the vaginal mucosa and reduced lubrication Two conditions not readily apparent on physical examination that produce dyspareunia are vulvar vestibulitis and interstitial cystitis Table 18-9 Neurophysiology of Sexual Dysfunction Erection 5DA HT NE ACh Clinical Correlation ↑ M Antipsychotics may lead to erectile dysfunction (DA block): DA agonists may lead to enhanced erection and libido; priapism with trazodone (α1, block); β-blockers may lead to impotence Ejaculation M α-Blockers (tricyclic drugs, MAOls, thioridazine) may lead to and impaired ejaculation; 5-HT agents may inhibit orgasm orgasm ↑, facilities; ↓, inhibits or decreases; ±, some; ACh, acetylcholine; DA, dopamine; 5-HT, serotonin; M, modulates; NE, norepinephrine; minimal Reprinted with permission from Segraves R Psychiatric Times 1990 C Male hypoactive sexual desire disorder and female interest/arousal disorder due to a general medical condition Sexual desire commonly decreases after major illness or surgery, particularly when the body image is affected after such procedures as mastectomy, ileostomy, hysterectomy, and prostatectomy In some cases, biochemical correlates are associated with hypoactive sexual desire disorder (Table 18-9) Drugs that depress the CNS or decrease testosterone production can decrease desire D Other male sexual dysfunction due to a general medical condition Delayed ejaculation can have physiologic causes and can occur after surgery on the genitourinary tract, such as prostatectomy It may also be associated with Parkinson’s disease and other neurologic disorders involving the lumbar or sacral sections of the spinal cord The antihypertensive drug guanethidine monosulfate (Ismelin), methyldopa (Aldomet), the phenothiazines, the tricyclic drugs, and the SSRIs, among others, have been implicated in retarded ejaculation (Table 18-10) E Other female sexual dysfunction due to a general medical condition Some medical conditions—specifically, endocrine diseases such as hypothyroidism, diabetes mellitus, and primary hyperprolactinemia— can affect a woman’s ability to have orgasms F Substance/medication-induced sexual dysfunction The diagnosis of substance-induced sexual dysfunction is used when evidence of substance intoxication or withdrawal is apparent from the history, physical examination, or laboratory findings The disturbance in sexual function must be predominant in the clinical picture See Table 18-11 In general, sexual function is negatively affected by serotonergic agents, dopamine antagonists, drugs that increase prolactin, and drugs that affect the autonomic nervous system With commonly abused substances, dysfunction occurs within a month of significant substance intoxication or withdrawal In small doses, some substances (e.g., amphetamine) may enhance sexual performance, but abuse impairs erectile, orgasmic, and ejaculatory capacities Oral contraceptives are reported to decrease libido in some women, and some drugs with anticholinergic side effects may impair arousal as well as orgasm Benzodiazepines have been reported to decrease libido, but in some patients the diminution of anxiety caused by those drugs enhances sexual function Both increase and decrease in libido have been reported with psychoactive agents Alcohol may foster the initiation of sexual activity by removing inhibition, but it also impairs performance Sexual dysfunction associated with the use of a drug disappears when the drug is discontinued Table 18-12 lists psychiatric medications that may inhibit female orgasm Table 18-10 Pharmacologic Agents Implicated in Male Sexual Dysfunctions Drug Psychiatric drugs Selective serotonin reuptake inhibitorsa Citalopram (Celexa) Fluoxetine (Prozac) Paroxetine (Paxil) Sertraline (Zoloft) Cyclic drugs Imipramine (Tofranil) Protriptyline (Vivactil) Desipramine (Pertofrane) Clomipramine (Anafranil) Amitriptyline (Elavil) Monoamine oxidase inhibitors Tranylcypromine (Parnate) Phenelzine (Nardil) Pargyline (Eutonyl) Isocarboxazid (Marplan) Other mood-active drugs Lithium (Eskalith) Amphetamines Trazodone (Desyrel)b Venlafaxine (Effexor) Antipsychoticsc Fluphenazine (Prolixin) Thioridazine (Mellaril) Chlorprothixene (Taractan) Mesoridazine (Serentil) Perphenazine (Trilafon) Trifluoperazine (Stelazine) Reserpine (Serpasil) Haloperidol (Haldol) Antianxiety agentd Chlordiazepoxide (Librium) Antihypertensive drugs Clonidine (Catapres) Methyldopa (Aldomet) Spironolactone (Aldactone) Hydrochlorothiazide (Hydrodiuril) Guanethidine (Ismelin) Impairs Erection Impairs Ejaculation – – – – + + + + + + + + + + + + + + + + – – + + – – + + – – – – + – + + + + – + + + + + + + + – + + + + + + + – – + Sertraline (Zoloft), 513 depression, 485 dosage and administration, 488, 488t drug interactions, 493, 494t half-life, 485 mood disorders, 183t OCD, 215 posttraumatic stress disorder, 227 Sex addiction, 297, 297t mood disorders and, 167 Sex-reassignment surgery, gender identity disorders and, 301 Sexsomnia, 337 Sex therapy, 453 Sexual arousal disorders, 283–285 female, 283–284, 284t male, 283, 284t Sexual aversion disorder, treatment of, 296 Sexual behavior compulsion (addiction), 344, 346 Sexual dysfunction, 283–303 See also specific disorders acquired type, 283 behavioral patterns, 297–298 classification of, 8–9 combined factors, 283 definition, 283 due to general medical condition, 82 female, 289 generalized type, 283 lifelong type, 283 male, 287, 288t, 289 neurophysiology of, 289 NOS, 296–298 opioid-induced, 115 pharmacologic agents implicated in, 291, 292t, 293 physiological factors, 283 psychological factors, 283 situational type, 283 SSRI-induced, 490 stimulant-induced, 122 substance/medication-induced, 9, 289, 291, 291t treatment, 291, 292t, 293–296 unspecified, 9 Sexually transmitted diseases (STDs), blood test for, 29 Sexual masochism, 12, 302t Sexual orientation, distress about, 297–298 Sexual sadism, 12, 302t Shared delusional disorder, 3 Shared psychotic disorder course and prognosis, 162 definition, 161 differential diagnosis, 162 epidemiology, 161 etiology, 161 psychodynamic factors, 161 signs and symptoms, 161, 161t treatment, 162 Sheehan’s syndrome, 90 Short-duration depressive episode, 4 Signal anxiety, 201 Sildenafil (Viagra), 490 erectile disorder, 82, 295 Sinemet See Carbidopa Single-photon emission computed tomography (SPECT), 46 Situational anxiety, 198 Skin-picking disorder See Excoriation Sleep, 328 and aging, 342 deprivation, 328 drunkenness, 340 hygiene, 331t insufficient, 340 NREM, 328 REM, 328–329 requirements, 328 stages, 328–329, 329t Sleep attacks See Excessive daytime somnolence Sleep bruxism, 339–340 Sleep disorders, 329–342 See also specific sleep disorders breathing-related, 333–336 circadian rhythm, 336 of clinical significance, 340–341 diagnosis, 425 DSM-5 classification, 329 due to general medical condition, 81 epidemiology, 425 etiology, 425 from general medical condition, 341–342 geriatric, 425 hypersomnolence disorder, 330–332 insomnia, 330 and mood disorder due to general medical condition, 78 narcolepsy, 332–333, 334t opioid-induced, 115 parasomnias, 336–339 signs/symptoms, 425 sleep-related movement disorders, 339–340 stimulant-induced, 122 Sleep drunkenness, 340 Sleep enuresis, 338 Sleep epilepsy, 341 Sleep-onset REM periods (SOREMPs), 332–333 Sleep paralysis, 332 recurrent isolated, 337 Sleep-related movement disorders, 339–340 due to drug or substance use, 340 due to medical condition, 340 periodic leg movement disorder, 339 restless legs syndrome, 339 sleep bruxism, 339–340 sleep-related leg cramps, 339 sleep rhythmic movement disorder, 340 Sleep rhythmic movement disorder, 340 Sleep talking, 340 Sleep terror disorder, 337 Sleep–wake disorders See also specific disorders circadian rhythm, 8 classification of, 8 substance/medication-induced, 8 Sleepwalking disorder, 336–337 SNRISs See Serotonin norepinephrine reuptake inhibitors Social anxiety disorder, 5, 193, 194t, 397 course and prognosis, 204 lifetime prevalence rates, 194t Social (pragmatic) communication disorders, 397–398 Social factors anorexia nervosa, 304, 306 bulimia nervosa, 310 Social judgment, 21 Social phobia, 5 See also Social anxiety disorder Social/pragmatic communication disorder, 1 Social skills training, 445 Sociocultural epidemiology, mood disorders and, 167 Sodium amobarbital (Amytal), 41 dissociative amnesia, 235 Sodium lactate, panic attack provocation with, 32 Somatic symptom disorder, 7, 245–247 clinical features, 246 course and prognosis, 246 differential diagnosis, 246 DSM-5 diagnostic criteria, 245 epidemiology, 245 etiology, 245 NOS, 258 pain disorder and, 256 psychotherapy in, 246 specified/unspecified, 258 treatment, 246–247 vs illness anxiety disorder, 246 Somatoform disorder factitious disorder and, 255 geriatric, 424 Somatropin (Humatrope), 279 Somnambulism See Sleepwalking disorder Somniloquy See Sleep talking Somnolence mirtazapine and, 499 SSRI-induced, 491 SOREMPs See Sleep-onset REM periods Spastic dysphonia, stuttering and, 397 Special K See Ketamine (Ketalar) Specific phobia, 5 See also Phobia Speech, mental status, 17 Speech sound disorder, 1, 395–396 Split treatment, 545–546 Spousal bereavement, 427 SSRIs See Selective serotonin reuptake inhibitors Stanozolol (Winstrol), 279 Stereotypic movement disorder, 2, 392 Steroids, hair-pulling disorder, 220 Stimulant-related disorders, 95, 119–123 anxiety disorder, 121 drugs and, 120 epidemiology, 120 intoxication and withdrawal, 120, 121t mood disorder, 121 obsessive–compulsive disorder, 121 psychotic disorder, 121 sexual dysfunction, 122 sleep disorder, 122 stimulant intoxication delirium, 121 treatment, 122 Stimulants, 516–520 See also Sympathomimetics hypersomnolence disorder, 330–332 Stranger anxiety, 198 Strattera See Atomoxetine Stress psychosomatic disorders and, 347, 349t response to, 347, 350t Stressor, 224 Stressor-related disorder See also specific disorders classification of, 6 Strokes, neuroimaging in, 43 Stuttering, 1, 396–397 Subacute spongiform encephalopathy, 88 See also Prion disease Subcortical arteriosclerotic encephalopathy See Binswanger’s disease Subpoena duces tecum, 546 Substance, 94 abuse, 95, 96t addiction, 95 co-dependence, 96 cross-tolerance, 96 dependence, 95, 95t intoxication, 96, 96t misuse, 95 neuroadaptation, 96 tolerance, 96 withdrawal, 96, 97t Substance abuse, urine testing for, 32, 33t Substance-induced anxiety disorder, 80 Substance-induced disorders, 94, 97 See also Substance-related disorders anxiety, 5 bipolar disorder, 4 classification of, 9–10 depressive disorder, 4 dissociative fugue and, 236 mood disorder, 4 and mood disorder due to general medical condition, 77–78 obsessive–compulsive disorder, 6, 216 psychotic disorder, 3 sexual dysfunction, 9, 289, 291, 291t sleep disorders, 8 Substance-induced persisting dementia, 69–70, 111 Substance-induced psychosis, 79, 152 Substance-induced psychotic disorder with delusions, 158 Substance/medication-induced anxiety disorder, 196, 198t Substance-related disorders, 94 alcohol dependence and abuse, 99–106 alcohol-induced persisting amnestic disorder, 111 alcohol-induced psychotic disorder, 108 alcohol intoxication, 106–108 alcohol-related disorders, 98–99 alcohol withdrawal, 109 alcohol withdrawal delirium, 109–110 caffeine-related disorders, 131 cannabis-related disorders, 123–125 DSM-5 classification of, 94 substance-induced disorders, 94 substance use disorders, 94 evaluation, 96–97 dependence and management, 98–99 history, 97 physical examination, 97 toxicology, 97, 98t hallucinogen-related disorders, 125–130 inhalant-related disorders, 130–131 opioid-related disorders, 111–115 sedative–hypnotic, and anxiolytic-related disorders, 115–119 stimulant-related disorders, 119–123 substance-induced persisting dementia, 111 terminology related to, 94–95 tobacco-related disorders, 131–132 Substance use disorders, 9, 94–95 See also Substance-related disorders geriatric, 424–425 signs and symptoms, 94–95 Suicidal behavior disorder, 13 Suicidal patient, management of, 362–365, 364t Suicide, 547 associated risk factors, 359–362, 360t definition, 359, 360t incidence/prevalence, 359 legal issues, 365–366 mental disorders and, 361–362, 361t method, 359 risk, 425 social context, 362, 363t–364t Sundowning, 80 Supportive psychotherapy anxiety disorders, 208 psychosomatic disorder, 350 Surgery, medical settings, 355t, 358 Sustenna, 471, 472, 484 Suvorexant (Belsomra), insomnia, 461 Symbyax, 515–516 Symmetrel See Amantadine Sympathomimetics, 516–520 attention-deficit/hyperactivity disorder, 516 clinical guidelines, 516–517 commonly used, 518t dosage and administration, 517 overdoses, 519 pharmacologic actions, 516 precautions and adverse reactions, 517, 519 pretreatment evaluation, 516–517 therapeutic efficacy, 516 treatment failures, 517 Syncope, 423, 426t Systemic lupus erythematosus, 89 T Tacrine (Cognex) Alzheimer’s disease, 64t tests related to, 32 therapeutic efficacy, 520 Tadalafil (Cialis), erectile disorder, 295 Tagamet See Cimetidine Tardive dyskinesia (TD), 12, 555 course and prognosis, 559 epidemiology, 559 neuroleptic-induced, 559–560 second-generation drugs and, 477 signs and symptoms, 559 treatment, 559–560 Tardive dystonia/akathisia, 12 TAT See Thematic apperception test TD See Tardive dyskinesia tDCS See Transcranial direct current stimulation Tegretol See Carbamazepine Temazepam (Restoril), insomnia, 460 Temperament, 279–280 psychobiology of, 281–282, 282t Temporal lobe epilepsy (TLE), 78, 85 dissociative fugue and, 235 Temporal lobe tumors, 86 Tenex See Guanfacine Testamentary capacity, 550 Testicular-feminizing syndrome See Androgen insensitivity syndrome Test judgment, 21 Testosterone, 279 Tetracyclic drugs blood concentrations, procedure for determining, 31 tests related to, 30–31 Thematic apperception test (TAT), 170, 202 Theramine (Sentra), 528t Therapeutic-graded exposure, 443 Therapeutic index, 457 Thiamine deficiency, 71, 92, 111 See also Korsakoff’s syndrome Thinking/perception, 18–19 abstract, 21 content of, 18 dreams, 19 fantasies, 19 form of, 18 perceptual disturbances, 18–19 thought disturbances, 18 Thiopental (Pentothal), dissociative amnesia, 235 Thought broadcasting, 18 continuity of, 18 disturbances, 18 insertion, 18 Thyroid disorders, 89–90 Thyroid function tests, 26 Tic disorders, 2 chronic motor, 393–394 chronic vocal, 393–394 stereotypic movement disorder and, 391 Tourette’s disorder, 392–393 TLE See Temporal lobe epilepsy TMS See Transcranial magnetic stimulation Tobacco-related disorders, 131–132 Tofranil See Imipramine Token economy, 443 Tolerance, 96, 457 Topiramate (Topamax) alcohol dependence, 104, 106t mood disorders, 184, 186 Tourette’s disorder, 2, 214 Transcranial direct current stimulation (tDCS), 542 mechanism of action, 542 side effects, 542 Transcranial magnetic stimulation (TMS), 542 indications, 542 side effects, 542 Transgender, 299 Transient global amnesia, 74–75, 233 differential diagnosis, 75, 75t pathology and laboratory examination, 74 Transsexualism, 301 Transvestic fetishism, 300, 302t Transvestism, 12 Trauma/stressor-related disorder, 6 See also specific disorders classification of, 6 Traumatic brain injury, 11 Trazodone (Desyrel), 184t, 494t, 500 bulimia nervosa and, 312 depressive disorder, 181 insomnia, 460 intermittent explosive disorder, 345 kleptomania, 345 posttraumatic stress disorder, 227 Trazodone-triggered priapism, 500 Treponema pallidum, 29 Triazolam (Halcion), 62 insomnia, 460 Trichotillomania See Hair-pulling disorder Tricyclic drugs, 501, 501t anxiety disorders, 206, 207t kleptomania, 345 nightmare disorder, 338 pain disorder, 256 parasomnias and, 339 sexual dysfunction and, 289 tests related to, 30–31 Trimipramine (Surmontil), mood disorders, 183t Trintellix See Vortioxetine Trinza, 471–472, 484 Tubby protein, 316t Turner’s syndrome, 300t U Ultrarapid detoxification, 114 United States v Brawner, 551 Uremic encephalopathy, 91 V Vaginismus, 287 treatment, 294 Vagus nerve stimulation (VNS), 543 definition, 543 patient selection, 543 Valbenazine (Ingrezza), tardive dyskinesia, 477, 555, 560 Valium See Diazepam Valproate (Depakene), 32, 506–511 antisocial personality disorder, 266 black box warnings, 511, 511t clinical guidelines, 509–510 dosage and administration, 509 formulations, 506 kleptomania, 345 laboratory monitoring, 509–510 mood disorders, 184 OCD, 215 pharmacologic actions, 506–507 posttraumatic stress disorder, 227 precautions and adverse reactions, 510–511, 510t, 511t during pregnancy, 511 pretreatment evaluation, 509 restless legs syndrome, 339 tests related to, 32 therapeutic efficacy, 507–509 depressive episodes, 508 maintenance treatment, 508–509 manic episodes, 507–508 Vardenafil (Levitra), erectile disorder, 295 Vascular dementia, 10, 43, 56, 64–66, 421 definition, 64–65 and dementia of Alzheimer’s type, 65 and depression, 65 differential diagnosis, 65 epidemiology, 65 laboratory tests, 65 signs and symptoms, 65 and strokes, 65 and transient ischemic attacks, 65 treatment, 65–66 Vasomax See Phentolamine VDRL test See Venereal disease research laboratory Venereal disease research laboratory (VDRL) test, 29 Venlafaxine (Effexor), 181, 215, 493–496, 494t anxiety disorders, 206, 207t attention-deficit/hyperactivity disorder, 402 clinical guidelines, 495–496 depressive disorder, 181 drug interactions, 496 hair-pulling disorder, 220 mood disorders, 183t, 412 parasomnias and, 339 pharmacologic actions, 495 precautions and adverse reactions, 496 therapeutic efficacy, 495 Verapamil (Isoptin), mood disorders, 186 Vertigo, 425–426 Viagra See Sildenafil Vilazodone, 494t, 500 Vinpocetine, 527t Violence definition, 366 diagnosis, 368 disorders associated with, 366 drug treatment, 368–369 evaluation, 366–368 history, 368 incidence/prevalence, 366 management, 366–368 predicting, 366 risk factors for, 368, 369t Violent patients, 547 Virilizing adrenal hyperplasia, 300t Virtual reality exposure of patients, 445 Visken See Pindolol Vistaril See Hydroxyzine hydrochloride Vitamin D, 527t Vitamin E family, 527t Vivactil See Protriptyline VNS See Vagus nerve stimulation Vocal tic disorder, 2 Vocational rehabilitation, 453 Vortioxetine (Trintellix), 494t, 500–501 dosage, 501 mood disorders, 183t side effects, 501 Voyeurism, 11, 302t Vraylar See Cariprazine Vyvanse See Lisdexamfetamine dimesylate W Warfarin, drug interactions, 493 Weight gain, SSRIs and, 490 Weight loss, diet for, 323, 324t Wellbutrin See Bupropion Wellbutrin SR, sustained release See Bupropion Wellbutrin XL, extended release See Bupropion XL Wernicke–Korsakoff syndrome, 10, 69 Wernicke’s encephalopathy, 10, 73, 111 Wills, 550 Wilson’s disease, 70, 352t Winstrol See Stanozolol Withdrawal alcohol, 109 benzodiazepine, 116, 116t, 117, 117t, 118t, 119t caffeine, 131 cannabis, 124 cocaine, 123 intoxication, 123 nicotine, 132 opioid use, 113–114 stimulant, 120, 121t substance, 96, 97t symptoms, 457 Written expression See Disorders of written expression Wyatt v Stickney, 548 X Xanax See Alprazolam Xenical See Orlistat Xyrem, 133 Y Yocon See Yohimbine Yohimbine (Yocon), erectile disorder, 296 Z Zaleplon (Sonata), insomnia, 460 Zinc, 525t Ziprasidone (Geodon), 190t, 515 adverse effects, 477 agitation associated with schizophrenia, 483 autism spectrum disorder, 397 clinical guidelines, 470t, 471 drug interactions, 479 pharmacological action, 466 schizophrenia in elderly, 423t Zoloft See Sertraline Zolpidem (Ambien) depressive disorder, 181 insomnia, 460 Zoophilia, 302t Zyban See Bupropion Zyprexa See Olanzapine Zyprexa Zydis (Orally disintegrating tablet) See Olanzapine About the Authors BENJAMIN JAMES SADOCK, M.D., is the Menas S Gregory Professor of Psychiatry in the Department of Psychiatry at the New York University (NYU) School of Medicine, New York, New York He is a graduate of Union College, received his M.D degree from New York Medical College, and completed his internship at Albany Hospital After finishing his residency at Bellevue Psychiatric Hospital, he entered military service, serving as Acting Chief of Neuropsychiatry at Sheppard Air Force Base, Wichita Falls, Texas He has held faculty and teaching appointments at Southwestern Medical School and Parkland Hospital in Dallas and at New York Medical College, St Luke’s Hospital, the New York State Psychiatric Institute, and Metropolitan Hospital in New York Dr Sadock joined the faculty of the NYU School of Medicine in 1980 and served in various positions: Director of Medical Student Education in Psychiatry, Co-Director of the Residency Training Program in Psychiatry, and Director of Graduate Medical Education, and is currently the Administrative Psychiatrist to the NYU School of Medicine He is on the staff of Bellevue Hospital and Tisch Hospital and is a Diplomate of the American Board of Psychiatry and Neurology and served as an Associate Examiner for the Board for more than a decade He is a Distinguished Life Fellow of the American Psychiatric Association, a Fellow of the American College of Physicians, a Fellow of the New York Academy of Medicine, and a member of Alpha Omega Alpha Honor Society He is active in numerous psychiatric organizations and is founder and president of the NYUBellevue Psychiatric Society Dr Sadock was a member of the National Committee in Continuing Education in Psychiatry of the American Psychiatric Association; he served on the Ad Hoc Committee on Sex Therapy Clinics of the American Medical Association, was a delegate to the conference on Recertification of the American Board of Medical Specialists, and was a representative of the American Psychiatric Association Task Force on the National Board of Medical Examiners and the American Board of Psychiatry and Neurology In 1985, he received the Academic Achievement Award from New York Medical College and was appointed Faculty Scholar at NYU School of Medicine in 2000 He is the author or editor of more than 50 books, is a book reviewer for psychiatric journals, and lectures on a broad range of topics in general psychiatry Dr Sadock maintains a private practice for diagnostic consultations and psychiatric treatment He has been married to Virginia Alcott Sadock, M.D., Professor of Psychiatry at NYU School of Medicine, since completing his residency Dr Sadock enjoys opera, golf, traveling, and is an enthusiastic fly fisherman SAMOON AHMAD, M.D., is Associate Professor of Psychiatry at the NYU School of Medicine and serves as Unit Chief of Bellevue Medical Center’s Acute Psychiatric Inpatient Unit Dr Ahmad graduated from Allama Iqbal Medical College in Lahore, Pakistan, where he trained in Internal Medicine, General Surgery, and Cardiology He has been affiliated with Bellevue Hospital since 1992, when he joined the NYU Medical Center as a Resident in Psychiatry Dr Ahmad joined the faculty of the NYU School of Medicine in 1996, where he was the Director of the Division of Continuing Medical Education (CME) He has served on various committees including Grand Rounds, CME Advisory, CME Task Force, Educational Steering, Bellevue Collaboration Council, and as member of the Bellevue Psychiatry’s Oversight Committee Dr Ahmad supervises and mentors trainees, lectures nationally and internationally on various topics, with emphasis on the use of antipsychotics, obesity, and metabolic disorders He is a Diplomate of the American Board of Psychiatry and Neurology and is also a Distinguished Fellow of the American Psychiatric Association, an Associate Member of the Royal College of Psychiatrists, and has served on the board of Governors of Bellevue Psychiatric Society Dr Ahmad developed Bellevue’s Psychiatry Integrated Systems Conference, based on the morbidity and mortality conference in medicine, to better coordinate services and treatment at the institution He was recognized for his 25 years of distinguished service at Bellevue, and in 2014, was named Bellevue’s Physician of the Year in Psychiatry for his continued pursuit of clinical excellence, leadership, and dedication at the institution His major research interests are in metabolic disorders and medical comorbidities in the mentally ill He was the principal investigator of an inpatient study about the prevalence of metabolic abnormalities in the chronically mentally ill, specifically the association of psychiatric medications, diet, physical activity, and obesity Additional research has focused on understanding the role of faith, religion, and resilience in disasters His documentary “The Wrath of God: A Faith Based Survival Paradigm” about the aftermath of the earthquake in Pakistan was awarded “The Frank Ochberg Award for Media and Trauma” by the International Society for Traumatic Stress Studies Dr Ahmad specializes in the psychopharmacologic treatment of psychotic, mood, anxiety, and substance use disorders and is the founder of the Integrative Center for Wellness in New York City He has consulted for numerous outside state and federal agencies, is a contributing and consulting editor to various textbooks, and lectures on a broad range of topics in general psychiatry He lives in New York City with his wife Kimberly and their son Daniel Dr Ahmad enjoys photography, traveling, driving, and collecting and listening to vinyl VIRGINIA ALCOTT SADOCK, M.D., joined the faculty of the NYU School of Medicine in 1980, where she is currently the Professor of Psychiatry and Attending Psychiatrist at the Tisch Hospital and Bellevue Hospital She is the Director of the Program in Human Sexuality at the NYU Medical Center, one of the largest treatment and training programs of its kind in the United States Dr Sadock is the author of more than 50 articles and chapters on sexual behavior and was the Developmental Editor of The Sexual Experience, one of the first major textbooks on human sexuality, published by Williams & Wilkins She serves as a referee and book reviewer for several medical journals, including the American Journal of Psychiatry and the Journal of the American Medical Association She has long been interested in the role of women in medicine and psychiatry and was a founder of the Committee on Women in Psychiatry of the New York County District Branch of the American Psychiatric Association She is active in academic matters, and served as an Assistant and Associate Examiner for the American Board of Psychiatry and Neurology for more than 15 years; and was a member of the Test Committee in Psychiatry for both the American Board of Psychiatry and the Psychiatric Knowledge and SelfAssessment Program (PKSAP) of the American Psychiatric Association She has chaired the Committee on Public Relations of the New York County District Branch of the American Psychiatric Association and has participated in the National Medical Television Network series Women in Medicine and the Emmy Award-winning PBS television documentary Women and Depression She hosts a weekly radio program on Sirius-XM called Sexual Health and Well-Being Dr Sadock has been the Vice-President of the Society of Sex Therapy and Research and a regional council member of the American Association of Sex Education Counselors and Therapists; she is currently the President of the Alumni Association of Sex Therapists of NYU Langone Medical Center She lectures extensively in the United States and abroad on sexual dysfunction, relational problems, and depression and anxiety disorders She is a Distinguished Fellow of the American Psychiatric Association, a Fellow of the New York Academy of Medicine, and a Diplomate of the American Board of Psychiatry and Neurology Dr Sadock is a graduate of Bennington College; she received her M.D degree from New York Medical College, and trained in psychiatry at Metropolitan Hospital She maintains an active practice that includes individual psychotherapy, couples and marital therapy, sex therapy, psychiatric consultation, and pharmacotherapy She lives in Manhattan with her husband Dr Benjamin Sadock They have two children, James William Sadock, M.D., and Victoria Anne Gregg, M.D., both emergency physicians, and four grandchildren, Celia, Emily, Oliver, and Joel In her leisure time, Dr Sadock enjoys theater, film, golf, reading fiction, and traveling ... Nervosa (%) 57 29 Binge-Eating and Purging Type Anorexia Nervosa (%) 100 44 57 0 57 43 29 14 66 11 33 67 11 22 11 14 56 14 33 14 0 71 22 33 100 3 or more codiagnoses Female Single Age (x ± SD) No of codiagnoses (x ±... fear of pain with sex These diagnoses are categorized into one diagnostic category but for the purposes of clinical discussion the distinct categories of dyspareunia and vaginismus remain clinically useful... aThe incidence of male erectile disorder associated with the use of tricyclic drugs is low bTrazodone has been causative in some cases of priapism cImpairment of sexual function is not a common complication of the use of antipsychotics Priapism has occasionally occurred in association with the use of antipsychotics