(BQ) Part 1 book “Pocket handbook of clinical psychiatry” has contents: Classification in psychiatry, psychiatric history and mental status examination, medical assessment and laboratory testing in psychiatry, brain imaging, major neurocognitive disorders,… and other contents.
KAPLAN & SADOCK’S POCKET HANDBOOK OF CLINICAL PSYCHIATRY Sixth Edition BENJAMIN J SADOCK, M.D Menas S Gregory Professor of Psychiatry Department of Psychiatry New York University School of Medicine Attending Psychiatrist, Tisch Hospital Attending Psychiatrist, Bellevue Hospital Center New York, New York SAMOON AHMAD, M.D Associate Professor of Psychiatry Department of Psychiatry New York University School of Medicine Attending Physician and Unit Chief Inpatient Psychiatry Bellevue Hospital Center New York, New York VIRGINIA A SADOCK, M.D Professor of Psychiatry Department of Psychiatry New York University School of Medicine Attending Psychiatrist, Tisch Hospital Attending Psychiatrist, Bellevue Hospital Center New York, New York Acquisitions Editor: Chris Teja Development Editor: Ashley Fischer Editorial Coordinator: Alexis Pozonsky Marketing Manager: Rachel Mante Leung Production Project Manager: Bridgett Dougherty Design Coordinator: Holly McLaughlin Manufacturing Coordinator: Beth Welsh Prepress Vendor: Aptara, Inc 6th edition Copyright © 2019 Wolters Kluwer Copyright © 2010 Wolters Kluwer Health / Lippincott Williams & Wilkins All rights reserved This book is protected by copyright No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews Materials appearing in this book prepared by individuals as part of their official duties as U.S government employees are not covered by the above-mentioned copyright To request permission, please contact Wolters Kluwer at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at permissions@lww.com, or via our website at lww.com (products and services) 9 8 7 6 5 4 3 2 1 Printed in China Library of Congress Cataloging-in-Publication Data Names: Sadock, Benjamin J., author | Ahmad, Samoon, author | Sadock, Virginia A., author Title: Kaplan & Sadock’s pocket handbook of clinical psychiatry / Benjamin J Sadock, Samoon Ahmad, Virginia A Sadock Other titles: Kaplan and Sadock’s pocket handbook of clinical psychiatry | Pocket handbook of clinical psychiatry | Complemented by (expression): Kaplan & Sadock’s comprehensive textbook of psychiatry 10th ed Description: Sixth edition | Philadelphia: Wolters Kluwer, [2019] | Complemented by: Kaplan & Sadock’s comprehensive textbook of psychiatry / editors, Benjamin J Sadock, Virginia A Sadock, Pedro Ruiz 10th ed 2017 | Includes bibliographical references and index Identifiers: LCCN 2017044540 | ISBN 9781496386939 (alk paper) Subjects: | MESH: Mental Disorders | Psychiatry | Handbooks Classification: LCC RC454 | NLM WM 34 | DDC 616.89—dc23 LC record available at https://lccn.loc.gov/2017044540 This work is provided “as is,” and the publisher disclaims any and all warranties, express or implied, including any warranties as to accuracy, comprehensiveness, or currency of the content of this work This work is no substitute for individual patient assessment based upon healthcare professionals’ examination of each patient and consideration of, among other things, age, weight, gender, current or prior medical conditions, medication history, laboratory data and other factors unique to the patient The publisher does not provide medical advice or guidance and this work is merely a reference tool Healthcare professionals, and not the publisher, are solely responsible for the use of this work including all medical judgments and for any resulting diagnosis and treatments Given continuous, rapid advances in medical science and health information, independent professional verification of medical diagnoses, indications, appropriate pharmaceutical selections and dosages, and treatment options should be made and healthcare professionals should consult a variety of sources When prescribing medication, healthcare professionals are advised to consult the product information sheet (the manufacturer’s package insert) accompanying each drug to verify, among other things, conditions of use, warnings and side effects and identify any changes in dosage schedule or contraindications, particularly if the medication to be administered is new, infrequently used or has a narrow therapeutic range To the maximum extent permitted under applicable law, no responsibility is assumed by the publisher for any injury and/or damage to persons or property, as a matter of products liability, negligence law or otherwise, or from any reference to or use by any person of this work LWW.com Dedicated to our children James and Victoria and to our grandchildren Celia, Emily, Oliver and Joel B.J.S V.A.S Dedicated to my parents Riffat and Naseem and my son Daniel S.A Preface Psychiatry underwent a sea change since the last edition of this book was published: A new classification of mental disorders was developed and codified in a fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) published by the American Psychiatric Association The reader will find all of those changes incorporated into this new, sixth edition of the Pocket Handbook of Clinical Psychiatry Every section in this book has been updated and revised and all the diagnoses of mental disorder conform to the criteria listed in DSM-5 Each disorder is described using the specific parameters of diagnosis, epidemiology, etiology, clinical signs and symptoms, differential diagnosis, and treatment This book serves as a ready reference to diagnose and treat the full range of mental disorders in both adults and children Over the years, psychiatrists and nonpsychiatric physicians have found it to be a useful guide as have medical students, especially during their rotations through psychiatry It is also used by psychologists, social workers, psychiatric nurses, and many other mental health professionals The Pocket Handbook is a minicompanion to the recently published encyclopedic tenth edition of Kaplan & Sadock’s Comprehensive Textbook of Psychiatry (CTP-X) and each chapter in this book ends with references to the more detailed relevant sections in that textbook The authors, Benjamin Sadock, M.D and Virginia Sadock, M.D are particularly pleased that Samoon Ahmad, M.D., a close friend and professional associate has joined them as a full author He is a distinguished psychiatrist with a national and international reputation as both an educator and clinician His participation has immeasurably helped and enhanced the preparation of this book We wish to thank several persons who have helped We want to acknowledge Norman Sussman, M.D who has collaborated with us as consulting and contributing editor in many Kaplan & Sadock books We also thank James Sadock, M.D and Victoria Sadock Gregg, M.D., experts in adult and child emergency medicine respectively, for their help Our assistant, Heidiann Grech was crucial in the preparation of this book for which we are most grateful As always, our publishers continue to maintain their high standards for which we are most appreciative At Wolters Kluwer, we especially want to thank Lexi Pozonsky for her help Finally, the authors wish to thank Charles Marmar, M.D., Lucius R Littauer Professor and Chair of the Department of Psychiatry at New York University School of Medicine Dr Marmar has developed one of this country’s premier psychiatric centers and has recruited outstanding clinicians, educators, and researchers who work in an academic environment conducive to outstanding productivity He has been most supportive of our work for which we are most grateful We hope this book continues to fulfill the expectations of all those for whom it is intended—the busy doctor-in-training, the clinical practitioner, and all those who work with and care for the mentally ill Benjamin J Sadock, M.D Samoon Ahmad, M.D Virginia A Sadock, M.D New York University Medical Center New York, New York Contents 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 Preface Classification in Psychiatry Psychiatric History and Mental Status Examination Medical Assessment and Laboratory Testing in Psychiatry Brain Imaging Major Neurocognitive Disorders Major or Minor Neurocognitive Disorder Due to Another Medical Condition (Amnestic Disorder) Mental Disorders Due to a General Medical Condition Substance-Related and Addictive Disorders Schizophrenia Spectrum and Other Psychotic Disorders Schizophreniform, Schizoaffective, Delusional, and Other Psychotic Disorders Mood Disorders Anxiety Disorders Obsessive–Compulsive and Related Disorders Trauma- and Stressor-Related Disorders Dissociative Disorders Somatic Symptom and Related Disorders Personality Disorders Sexual Dysfunction and Gender Dysphoria Feeding and Eating Disorders Obesity and Metabolic Syndrome Normal Sleep and Sleep–Wake Disorders Disruptive, Impulse-Control, and Conduct Disorders Psychosomatic Medicine Suicide, Violence, and Emergency Psychiatric Medicine Child Psychiatry Geriatric Psychiatry c More common in men than in women d A familial transmission is suspected Etiology A commonly cited factor is a failure in maternal empathy, with early rejection or loss Table 17-8 Narcissistic Personality Disorder A temperament defined by heightened sense of self, the seeking of reverence from others, and callousness marked by ≥5 of: Exaggerated sense of self-worth Imagined possession of extreme power, intelligence, glamour, or other typically beneficial qualities Abiding sense of exclusivity A need for adulation or adoration A sense of privilege Selfish use of others Callousness and ignorance of others Jealousness of others Hubris Psychodynamics Grandiosity and empathic failure defend against primitive aggression The grandiosity is commonly viewed as a compensation for a sense of inferiority Diagnosis Patients with narcissistic personality disorder have a grandiose sense of self-importance, whether in fantasy or in behavior They have a great need for admiration, lack empathy, and often have chronic, intense envy They handle criticism or defeat poorly; they either become enraged or depressed Fragile self-esteem and interpersonal relationships are evident Common stresses produced by their behavior are interpersonal difficulties, occupational problems, rejection, and loss See Table 17-8 Differential diagnosis a Antisocial personality disorder The patient overtly disregards the law and the rights of others b Paranoid schizophrenia The patient has overt delusions c Borderline personality disorder The patient shows greater emotionality, greater instability d Histrionic personality disorder The patient displays more emotion Course and prognosis The disorder can be chronic and difficult to treat Aging is handled poorly because it is a narcissistic injury; therefore, they are more vulnerable to midlife crises Possible complications include mood disorders, transient psychoses, somatoform disorders, and substance use disorders The overall prognosis is guarded Treatment a Psychotherapy Patients must renounce narcissism to make progress, making treatment rather difficult Some clinicians suggest psychoanalytic approaches to effect change, but more research is needed Group therapy has proved useful in helping patients share with others and develop an empathic response to others b Pharmacotherapy Lithium (Eskalith) is useful in patients with mood swings while antidepressants, especially serotonergic agents, are useful in depression IV Anxious or Fearful Cluster A Obsessive-compulsive personality disorder Definition Characterized by perfectionism, orderliness, inflexibility, stubbornness, emotional constriction, and indecisiveness Also called anancastic personality disorder Epidemiology a The prevalence is 1% in the general population and 3% to 10% in outpatients b The prevalence is greater in men than in women c Familial transmission is likely d The concordance is increased in monozygotic twins e The disorder is diagnosed most often in oldest children Etiology Patients may have backgrounds characterized by harsh discipline Psychodynamics a Isolation, reaction formation, undoing, intellectualization, and rationalization are the classic defenses b Emotions are distrusted c Issues of defiance and submission are psychologically important d Fixation at the anal period Diagnosis Patients with obsessive-compulsive personality disorder have a stiff, formal, and rigid demeanor They lack spontaneity and their mood is usually serious In an interview, patients may be anxious about not being in control and their answers to questions are unusually detailed Patients with obsessive-compulsive personality disorder are preoccupied with rules, regulations, orderliness, neatness, and details Patients lack interpersonal skills; they often lack a sense of humor, alienate people, and are unable to compromise However, they are eager to please powerful figures and carry out these people’s wishes in an authoritarian manner See Table 17-9 Differential diagnosis The patient with obsessive-compulsive disorder has true obsessions or compulsions, whereas the patient with obsessive-compulsive personality disorder does not Course and prognosis The course of this disorder is variable and unpredictable The patient may flourish in arrangements in which methodical or detailed work is required The patient’s personal life is likely to remain barren Complications of anxiety disorders, depressive disorders, and somatoform disorders may develop Table 17-9 Obsessive-Compulsive Personality Disorder An enduring focus on neatness and control (≥4 of the following): Excessive concern with regulations, timing, organization, or specific detail Perfectionistic performance standards that prevent accomplishment Prioritization of productivity and labor at the expense of leisure or rest Overly rigid adherence to rules and moral standards Hoarding possessions Unwillingness to cede control Parsimonious spending habits Hardheaded temperament Treatment a Psychotherapy Patients with obsessive-compulsive personality disorder are aware of their suffering and often seek treatment on their own Treatment is often long and complex, and counter transference problems are common Patients value free association and nondirective therapy b Pharmacotherapy Clonazepam (Klonopin) is useful in reducing symptoms Clomipramine (Anafranil) and serotonergic agents such as fluoxetine, with dosages of 60 to 80 mg/day, may be useful if obsessive-compulsive signs and symptoms break through Atypical antipsychotics such as quetiapine (Seroquel) may be of use in severe cases B Avoidant personality disorder Definition Patients have a shy or timid personality and show an intense sensitivity to rejection They are not asocial and show a great desire for companionship; however, they have a strong need for reassurance and a guarantee of uncritical acceptance They are sometimes described as having an inferiority complex Epidemiology a The prevalence is 0.05% to 1% of the general population and 10% of outpatients b Possible predisposing factors include avoidant disorder of childhood or adolescence or a deforming physical illness Etiology Overt parental deprecation, overprotection, or phobic features in the parents themselves are possible etiologic factors Psychodynamics a The avoidance and inhibition are defensive b The overt fears of rejection cover underlying aggression, either oedipal or preoedipal Diagnosis In clinical interviews, patients are often anxious about talking to the interviewer Their nervous and tense manner appears to wax and wane with their perception of whether the interviewer likes them Patients may be vulnerable to the interviewer’s comments and suggestions and may perceive a clarification or an interpretation as criticism See Table 17-10 Table 17-10 Avoidant Personality Disorder A temperament characterized by social withdrawal because of increased sensitivity to others’ criticism demonstrated by ≥4 of: Avoidance of social situations because of a desire to minimize criticism Disengagement from relationships because of fear of others’ disapproval Unwillingness to become intimate due to a sense of embarrassment Excessive concern about social rejection Withdrawal from new social situations Negative self-concept Avoidance of risk and novelty because of fear of shame and ridicule Differential diagnosis a Schizoid personality disorder The patient has no overt desire for involvement with others b Social phobia Specific social situations, rather than personal relationships, are avoided The disorders may coexist c Dependent personality disorder The patient does not avoid attachments and has a greater fear of abandonment Disorders may coexist d Borderline and histrionic personality disorders The patient is demanding, irritable, and unpredictable Course and prognosis Patients function best in a protected environment Possible complications are social phobia and mood disorders Treatment a Psychotherapy Psychotherapeutic treatment depends on solidifying an alliance with patients As trust develops, it is crucial that a clinician conveys an accepting attitude toward the patient’s fears, especially that of rejection Clinicians should be cautious about giving assignments to exercise the patient’s new social skills outside of therapy, because failure may reinforce patients’ poor self-esteem Group therapy is helpful in gaining an understanding of the effects that sensitivity to rejection has on themselves and others Assertive training in behavior therapy may help teach patients to openly express their needs and to enhance their selfesteem b Pharmacotherapy Pharmacotherapy is useful in managing anxiety and depression β-Adrenergic receptor antagonists, such as atenolol (Tenormin), is helpful in managing hyperactivity in the autonomic nervous system, which is especially high when approaching feared situations Serotonergic agents are helpful with rejection sensitivity Dopaminergic agents may cause more novelty-seeking behavior in these patients, but the patient needs to be psychologically prepared for any new experiences that may occur as a result C Dependent personality disorder Definition Patients are predominantly dependent and submissive They lack self-confidence and get others to assume responsibility for major areas of their lives Epidemiology a The disorder is more prevalent in women than in men; however, it may be underdiagnosed in men b The disorder is common, possibly accounting for 2.5% of all personality disorders c More common in young children than in older ones Etiology Chronic physical illness, separation anxiety, or parental loss in childhood may predispose Psychodynamics a Unresolved separation issues are present b The dependent stance is a defense against aggression Table 17-11 Dependent Personality Disorder A recurrent state of subordination to the care of others manifest by ≥5 of: Indecisiveness and reliance on other parties when making everyday choices Deferral of responsibility for most aspects of life to others Reluctance to voice opposition Diffidence precluding taking actions on one’s initiative Willingness to debase oneself for approval Feelings of isolation or desolation when alone because of fears of incompetence Recurrent need to seek replacement support figures Excessive anxiety about having to take care of oneself Diagnosis Persons with dependent personality disorder have an intense need to be taken care of, which leads to clinging behavior, submissiveness, fear of separation, and interpersonal dependency In interviews, they appear rather compliant; they try to cooperate, welcome specific questions, and look for guidance They are passive and have difficulty expressing disagreement Patients are pessimistic, passive, indecisive, and fear expressing sexual or aggressive feelings In folie deux (shared psychotic disorder), one member of the pair usually suffers from this disorder; the submissive partner takes on the delusional system of the more aggressive, assertive partner on whom he or she is dependent See Table 17-11 Differential diagnosis a Agoraphobia The patient is afraid of leaving or being away from home b Histrionic and borderline personality disorders The patient has a series of dependent relationships and is overly manipulative Course and prognosis The course of dependent personality disorder is variable Depressive complications are possible if a relationship is lost The prognosis can be favorable with treatment The patient may not be able to tolerate the “healthy” step of leaving an abusive relationship Treatment a Psychotherapy Insight-oriented therapies are helpful in enabling patients to understand the antecedents of their behavior, thereby enabling them to become more independent, assertive, and selfreliant Behavior therapy, assertiveness training, family therapy, and group therapy have also been successful Clinicians must respect patients’ feelings of attachment in pathologic relationships b Pharmacotherapy Pharmacotherapy has been used in managing specific symptoms such as anxiety or depression Alprazolam (Xanax) has been useful in patients who experience panic attacks If a patient’s depression or withdrawal symptoms respond to psychostimulants, they may be used Benzodiazepines and serotonergic agents have also been used successfully V Other Specified Personality Disorders In DSM-5, the category other specified personality disorder is reserved for disorders that not fit into any of the personality disorder categories described above Passive-aggressive personality and depressive personality are examples A narrow spectrum of behavior or a particular trait—such as oppositionalism, sadism, or masochism—can also be classified in this category A patient with features of more than one personality disorder but without the complete criteria of any one disorder can be assigned this classification A Passive-aggressive personality Passive-aggressive personality was once considered a psychiatric diagnosis but is no longer classified as such It is included here because persons with this personality type are not uncommon Definition Patients with this disorder show aggression in passive ways characterized by obstructionism, procrastination, stubbornness, and inefficiency It is also called negativistic personality disorder Epidemiology Unknown Etiology a May involve learned behavior and parental modeling b Early difficulties with authority common Psychodynamics a Conflicts regarding authority, autonomy, and dependence b Uses passive modes to express defiance and aggression Diagnosis Patients with passive-aggressive personality disorder are passive, sullen, and argumentative They resist demands for adequate performance in social and occupational tasks and unreasonably criticize and scorn authority They complain of being misunderstood and unappreciated and exaggerate personal misfortune They are both envious and resentful of those whom they deem more fortunate They tend to alternate between hostile defiance and guilt Differential diagnosis a Histrionic and borderline personality disorders The patient’s behavior is more flamboyant, dramatic, and openly aggressive b Antisocial personality disorder The patient’s defiance is overt c Obsessive-compulsive personality disorder The patient is overtly perfectionistic and submissive Course and prognosis Association with depressive disorders and alcohol abuse in approximately 50% of patients Prognosis is guarded without treatment Treatment a Psychotherapy Psychotherapy can be successful with these patients but requires that clinicians point out the consequences of passive-aggressive behaviors as they occur Such confrontations may be more helpful than a correct interpretation in changing patients’ behavior Clinicians must treat suicide gestures as a covert expression of anger rather than as object loss in major depressive disorder b Pharmacotherapy Antidepressants are used when clinical indications of depression and suicidal ideation exist Some patients respond to benzodiazepines and psychostimulants, depending on the clinical features B Depressive personality Definition Patients are characterized by depressive traits that last that have been prevalent throughout their lives, such as pessimism, self-doubt, and chronic unhappiness They are introverted passive and duty bound Epidemiology a The disorder is thought to be common, but no data are available b Probably occurs equally in men and women c Probably occurs in families with depression Etiology Chronic physical illness, separation anxiety, or parental loss in childhood may predispose Psychodynamics a Unresolved separation issues are present b The dependent stance is a defense against aggression Diagnosis Patients with depressive personality disorder often complain of chronic feelings of unhappiness They admit to low selfesteem and have difficulty finding anything joyful, hopeful, or optimistic in their lives They are self-critical and derogatory and are likely to denigrate their work, themselves, and their relationships with others Their physiognomy often reflects their mood—poor posture, depressed facies, soft voice, and psychomotor retardation Differential diagnosis a Dysthymic disorder Fluctuations in mood are greater than in depressive personality disorder b Avoidant personality disorder The patient tends to be more anxious than depressed Course and prognosis A risk for dysthymic disorder, major depressive disorder, and current or lifetime mood disorder is thought to be likely Treatment a Psychotherapy Insight-oriented psychotherapy enables patients to gain insight into the psychodynamics of their illness and to appreciate the effect it has on their interpersonal relationships Cognitive therapy corrects the cognitive manifestation of their low self-esteem and pessimism Group therapy, interpersonal therapy, and self-help measures are also useful b Pharmacotherapy Pharmacotherapy for depressive personality disorder patients includes the use of antidepressant medications Serotonergic agents are especially useful Small dosages of psychostimulants, such as amphetamine at to 15 mg/day, have been helpful for some patients These approaches should be combined with psychotherapy for best results C Sadomasochistic personality Not an official diagnostic but is of major interest to physicians clinically and historically It is characterized by elements of sadism, the desire to cause others pain sexually, physically, or psychologically, and masochism, inflicting pain on oneself either sexually or morally Treatment with insight-oriented psychotherapy, including psychoanalysis, can be effective D Sadistic personality Patients show a pervasive pattern of cruel, demeaning, and aggressive behavior toward others Physical cruelty and violence are used to inflict pain on others with no actual goal Such patients are usually fascinated with weapons, violence, injury, and torture It is often related to parental abuse E Personality change due to a general medical condition Personality change due to a general medical condition is a significant occurrence These include brain disease, damage, and dysfunction, which includes organic personality disorder, postencephalitic syndrome, and postconcussional syndrome It is characterized by a marked change in personality style and traits from a previous level of functioning Diagnosis and clinical features A change in personality from previous patterns of behavior with impaired impulse control and expression of emotions Euphoria or apathy may be prominent as well as excitement and facile jocularity with injury to the frontal lobes Frontal lobe syndrome consists of indifference and apathy, lack of concerns and temper outbursts that can result in violent behavior Persons with temporal lobe epilepsy characteristically show humorlessness, hypergraphia, hyperreligiosity, and marked aggressiveness during seizures See Table 17-12 Etiology Structural damage to the brain is usually the cause of the personality change, and head trauma is probably the most common cause The conditions most often associated with personality change are listed in Table 17-13 Table 17-12 Personality Change Due to Another Medical Condition An enduring change in personality attributable to a medical condition (In children, this must last more than a year) (Delirium is a red flag) Subtypes include: Labile: marked by heightened emotional variability Disinhibited: marked by indomitable impulses or appetites Aggressive: marked by violent or enraged behavior Apathetic: marked by detachment Paranoid: marked by distrust Combined: marked by a mixture of any of the subtypes Other: adhering to none of the outlined subtypes Unspecified Table 17-13 Medical Conditions Associated with Personality Change Head trauma Cerebrovascular diseases Cerebral tumors Epilepsy (particularly, complex partial epilepsy) Huntington’s disease Multiple sclerosis Endocrine disorders Heavy metal poisoning (manganese, mercury) Neurosyphilis Acquired immune deficiency syndrome (AIDS) F Anabolic steroids Large number of high school and college athletes and bodybuilders are using anabolic steroids for physical development These include oxymetholone (Anadrol), somatropin (Humatrope), stanozolol (Winstrol), and testosterone Anabolic steroids can cause persistent alterations of personality and behavior Differential diagnosis In differentiating the specific syndrome from other disorders in which personality change may occur—such as schizophrenia, delusional disorder, mood disorders, and impulse control disorders—physicians must consider the presence in personality change disorder of a specific organic causative factor Course and prognosis In structural damage to the brain, the disorder tends to persist In head trauma or vascular accident damage and may be permanent The personality change can evolve into dementia in cases of brain tumor, multiple sclerosis, and Huntington’s disease Treatment Management of personality change disorder involves treatment of the underlying organic condition when possible Psychopharmacological treatment of specific symptoms may be indicated in some cases, such as imipramine or fluoxetine for depression Patients with severe cognitive impairment need counseling and patients’ families may require emotional support VI Psychobiological Model of Treatment The psychobiological model of treatment combines psychotherapy and pharmacotherapy and can be systematically matched to the personality structure and stage of character development The newest development is treating personality disorders pharmacologically Table 17-14 summarizes drug choices for various target symptoms of personality disorders A Temperament Temperament refers to the body’s biases in the modulation of conditioned behavioral responses to prescriptive physical stimuli It is conceptualized as the stylistic component (“how”) of behavior, as differentiated from the motivation (“why”) and the content (“what”) of behavior Four major temperament traits have been identified and include: harm avoidance, novelty seeking, reward dependence, and persistence Table 17-14 Pharmacotherapy of Target Symptom Domains of Personality Disorders Target Symptom I Behavior dyscontrol Aggression or impulsivity Affective aggression (hot temper with normal EEG) Predatory aggression (hostility or cruelty) Organic-like aggression Ictal aggression (abnormal EEG) II Mood dysregulation Emotional lability Depression Atypical depression, dysphoria Emotional detachment III Anxiety Chronic cognitive Chronic somatic a Drug of Choice Contraindication Lithiuma ? Benzodiazepines Serotonergic drugsa Anticonvulsantsa Low-dosage antipsychotics Antipsychoticsa Lithium β-Adrenergic receptor antagonists Imipraminea Cholinergic agonists (donepezil) Carbamazepinea Diphenylhydantoina Benzodiazepines Stimulants Benzodiazepines Stimulants Lithiuma Antipsychotics ? Tricyclic drugs MAOIsa Serotonergic drugsa Antipsychotics Serotonin-dopamine antagonistsa Atypical antipsychotics ? Tricyclic drugs Serotonergic drugsa MAOIsa Benzodiazepines MAOIsa β-Adrenergic receptor antagonists Stimulants Antipsychotics Stimulants Severe anxiety IV Psychotic symptoms Acute and psychosis Chronic and low-level psychotic-like symptoms Low-dose antipsychotics MAOIs Antipsychoticsa Low-dose antipsychoticsa Stimulants aDrug of choice or major contraindication EEG, electroencephalogram; MAOI, monoamine oxidase inhibitor B Biologic character traits Four character traits have been described and mentioned in Table 17-15 It summarizes contrasting sets of behaviors that distinguish extreme scorers on the four dimensions of temperament Harm avoidance High harm avoidance is observed as fear of uncertainty, social inhibition, shyness with strangers, rapid fatigability, and pessimistic worry in anticipation of problems even in situations that do not worry other persons Persons low in harm avoidance are carefree, courageous, energetic, outgoing, and optimistic even in situations that worry most persons Table 17-15 Descriptors of Individuals Who Score High or Low on the Four Temperament Dimensions Temperament Dimension Harm avoidance Novelty seeking Reward dependence Persistence Descriptors of Extreme Variants High Low Pessimistic Optimistic Fearful Daring Shy Outgoing Fatigable Energetic Exploratory Reserved Impulsive Deliberate Extravagant Thrifty Irritable Stoical Sentimental Detached Open Aloof Warm Cold Affectionate Independent Industrious Lazy Determined Spoiled Enthusiastic Underachiever Perfectionist Pragmatist Novelty seeking Novelty seeking is observed as exploratory activity in response to novelty, impulsiveness, extravagance in approach to cues of reward, and active avoidance of frustration Individuals high in novelty seeking are quick tempered, curious, easily bored, impulsive, extravagant, and disorderly Persons low in novelty seeking are slow tempered, uninquiring, stoical, reflective, frugal, reserved, tolerant of monotony, and orderly Reward dependence Individuals high in reward dependence are tender hearted, sensitive, socially dependent, and sociable Individuals low in reward dependence are practical, tough minded, cold, socially insensitive, irresolute, and indifferent if alone Persistence Highly persistent persons are hard-working, perseverant, and ambitious overachievers who tend to intensify their effort in response to anticipated rewards and view frustration and fatigue as personal challenges Individuals low in persistence are indolent, inactive, unstable, and erratic; they tend to give up easily when faced with frustration, rarely strive for higher accomplishments, and manifest little perseverance even in response to intermittent reward C Psychobiology of temperament Temperament traits of harm avoidance, novelty seeking, reward dependence, and persistence are defined as heritable differences underlying automatic responses to danger, novelty, social approval, and intermittent reward, respectively The neurobiologic model of learning in animals is summarized in Table 17-16 This model distinguishes four dissociable brain systems for behavioral inhibition (harm avoidance), behavioral activation (novelty seeking), social attachment (reward dependence), and partial reinforcement (persistence) Table 17-16 Four Dissociable Brain Systems Influencing Stimulus–Response Patterns Underlying Temperament Brain System (Related Personality Dimension) Behavioral inhibition (harm avoidance) Principal Neuromodulators Relevant Stimuli GABA Aversive conditioning (pairing Serotonin (dorsal CS and UCS) raphe) Conditioned signals for punishment and frustrative Behavioral Response Formation of aversive CS Passive nonreward avoidance Extinction Behavioral activation Dopamine Novelty Exploratory (novelty seeking) CS of reward pursuit CS or UCS of relief of monotony Appetitive or punishment approach Active avoidance Escape Social attachment (reward Norepinephrine Reward conditioning (pairing CS Formation of dependence) Serotonin (median and UCS) appetitive raphe) CS Partial reinforcement Glutamate Intermittent (partial) Resistance to (persistence) Serotonin (dorsal reinforcement extinction raphe) CS, conditioned stimulus; GABA, γ-aminobutyric acid; UCS, unconditioned stimulus Adapted from Cloninger CR A systematic method for clinical description and classification of personality variables Arch Gen Psychiatry 1987;44:573 They have been shown to be universal across different cultures, ethnic groups, and political systems In summary, these aspects of personality are called temperament because they are heritable, manifest early in life, are developmentally stable, and are consistent in different cultures For more detailed discussion of this topic, see Chapter 57, Personality Disorders, Section 57.3i, p 4103, in CTP/X ... Title: Kaplan & Sadock’s pocket handbook of clinical psychiatry / Benjamin J Sadock, Samoon Ahmad, Virginia A Sadock Other titles: Kaplan and Sadock’s pocket handbook of clinical psychiatry | Pocket handbook of clinical psychiatry | Complemented by (expression): Kaplan &... Contents 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 Preface Classification in Psychiatry Psychiatric History and Mental Status Examination Medical Assessment and Laboratory Testing in Psychiatry. .. KAPLAN & SADOCK’S POCKET HANDBOOK OF CLINICAL PSYCHIATRY Sixth Edition BENJAMIN J SADOCK, M.D Menas S Gregory Professor of Psychiatry Department of Psychiatry New York University School of Medicine